‘I will never have closure’ bereaved mother tells court
A MOTHER told an inquest court yesterday that the criminal investigation into her daughter’s death has been ‘unbearable’ and she ‘will never have closure’.
Lauren Ellis, pictured, was 22 when she died while she was a voluntary inpatient at the Crevichon Ward at the Oberlands in the early hours of 12 October 2017.
Speaking at the conclusion of the inquest into her daughter’s death almost seven years later, Dawn Ellis said that the criminal case and delay in the inquest had kept the pain raw.
‘Today is 2,360 days since Lauren passed away,’ she said.
‘Lauren’s passing has affected the family and her friends terribly. She had a huge personality and an infectious laugh, she was loud. We have our memories of Lauren, but since 12 October 2017 we have no new ones.
‘The criminal investigation into Lauren’s passing is well-known. Losing a daughter or sister is bad enough, but hearing shortly after that the police were so concerned about the level of treatment that arrests were made was unbearable.’
At 12.30am on 11 October 2017, Lauren Ellis’s partner found her at home with a self-inflicted laceration to her forearm. She was treated at A&E and discharged.
After a second trip to hospital the same day, Miss Ellis agreed to spend some time at the Oberlands Centre on a voluntary basis.
Her partner and family said she appeared in a happier mood when she was there.
Miss Ellis was put under level two observations, and her whereabouts and activity had to be documented every 15 minutes.
‘Lauren phoned me at around 10.30pm, we spoke for around an hour. After the call I was concerned that Lauren might self-harm and phoned the ward to tell them. I was assured by the nurse I spoke to not to worry and they would look after Lauren,’ said Ms Ellis.
‘The next contact we had from the hospital was a call to tell me that Lauren had harmed, and we should make our way to the hospital. There was no indication from that call on how serious the situation was.’
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At approximately 2.45am Miss Ellis was found lying on the floor. 50 minutes later she was pronounced dead.
Criminal proceedings into the nurses working that night found that they had failed to carry out the 15-minute observations that had been specified, and the official records of the checks that should have been carried out were falsified.
‘We have since become aware of other failings such as the machine used to try to clear Lauren’s airways was faulty, doors were locked preventing emergency access and the wrong number was dialled when the ambulance was called, resulting in another delay in emergency care,’ said Ms Ellis.
‘Lauren applied the ligature herself, however we remain convinced she would have applied this around the time a 15-minute observation was due as she was familiar with the routine.
‘We will always feel the individual and collective failings of the hospital contributed to us losing her.’
A post-mortem concluded the cause of death to be ligature strangulation, with a possible contribution from positional asphyxia.
Deputy Judge Graeme McKerrell yesterday delivered an open verdict due to the uncertainty of how Miss Ellis came by her death.
In the wake of the death, internal and external investigations were carried out to identify areas where improvements could be made in the Guernsey mental health service.
Two former HSC nurses were found not guilty of manslaughter by gross negligence in 2019.
