Ellis case: ‘clear indication suicide risk level had changed’

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IT BEGGARED belief that Lauren Ellis was not considered a high suicide risk when she was admitted to The Oberlands Mental Health Centre, an expert told the Royal Court yesterday.

Lauren Ellis was a vulnerable patient who died at the Oberlands Mental Health Centre in October 2017. She was 22. (Picture supplied by family)

Appearing by video link for the defence, Royal College of Psychiatrists member Dr John Pilgrim said that the 22-year-old had not been properly assessed and there was clear indication in the hours before her death that the risk level had changed.

Miss Ellis died on Crevichon Ward in the early hours of 12 October 2017.

A post-mortem examination found she had died through ligature strangulation.

Nurses Rory McDermott, 32, and Naomi Prestidge, 31, deny the joint unlawful killing of her through gross negligence.

Miss Ellis had attended at The Princess Elizabeth Hospital three times in the 12 hours prior to death.

On the first occasion she had suicidal urges, on the second she had caused a serious wound by self-harming with a knife, and on the third she had applied a ligature. Also, in the days prior, her boyfriend had found her unconscious after a ligature had been applied.

Dr Pilgrim said staff in the mental health service and the PEH emergency department were not sufficiently trained in emotionally unstable personality disorder – the condition with which Miss Ellis has been diagnosed. The lack of training might explain why things did not happen as they should have done in Lauren’s case.

People with EUPD could be absolutely fine one minute and suicidal the next, he said. Flashbacks could prompt impulsive, reckless and unexplained acts based on uncontrollable urges.


Medical staff had put too much focus on the fact that Miss Ellis had still had capacity. Given the levels of medication that she was on, which Dr Pilgrim said was ‘bucket loads’, the treating team had thought that she was at the most severe end of those suffering EUPD.

The suicide rate of EUPD sufferers was about 10% but in Miss Ellis’ case it would probably have been higher.

The court heard how psychiatrist Dr Rahul Bhintade had put Miss Ellis on level two observations, meaning she should be checked every 15 minutes.

The court also heard how Mr McDermott and Miss Prestidge had failed to carry out six checks in a row and there had been one hour and 42 minutes between the last check and the discovery of what had happened.


Level two observations meant that if a patient self-harmed he or she could leave the unit whenever they wanted to.

Dr Pilgrim believed Miss Ellis should have been placed on level three, which would have meant constant observation and the option of sectioning someone under the mental health law to ensure their safety.

Crown advocate Chris Dunford asked if it was not counter-intuitive to look at level three observations when the ones at level two had not been performed?

Dr Pilgrim accepted counsel’s submission that it was horrendous and unacceptable that the checks had not been carried out and said they should have been. It had been a grave breach of duty to the patient.

He said a note that Dr Bhintade had written following Miss Ellis’ admission to the ward had been too brief, with no clear risk assessment and background history was minimal.

Notes should be done contemporaneously but Dr Bhintade had amended them 12 days later.

This could have given the impression to nursing staff that risk was minimal and one might question why she was there at all.

Advocate Dunford said both defendants had been involved with Lauren’s care before. They knew of her EUPD and the fact that she would very seriously self-harm.

He said Dr Pilgrim had been talking with hindsight and it was very easy to say what could or should have happened when somebody knew the outcome.

The case continues.

Nigel Baudains

By Nigel Baudains
News reporter

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