Codie Lee Black, of Tyneside, died in the Carleton Clinic on January 31, 2023, while she was subject to detention under the Mental Health Act.
She had been found by nursing staff having drowned in a bath, despite being required to be monitored every ten minutes.
During a hearing at Cockermouth Coroner’s Court that lasted five days, Assistant Coroner for Cumbria, Ms Margaret Taylor, heard evidence from 18 live witnesses along with five written submissions, to determine the circumstances around Ms Black’s death.
She said: “She was an artistically talented young woman, but one whose childhood had been blighted by the acts of sexual abuse committed by an older man on her at the age of 13.
“Following this abuse, her behaviour changed and so began her involvement with mental health services, which would continue until her untimely and tragic death.
“She had multiple contacts with emergency services, triggered by her suicidal ideation and self-harm.”
From the age of 13, Ms Black had been admitted to children’s inpatients wards with follow-up in the community from children’s and young persons’ services, and was detained under the Mental Health Act for five months in 2018.
After this, her self-harm continued, and Ms Black was transferred to a secure placement, where she was in regular contact with her
As she approached the age of 18, she was faced with the transition from children’s to adult mental health services, which she found ‘very daunting, in common with many young people’.
Ms Black was deemed to have capacity to discharge in May 2022, as she wanted ‘a break from mental health services’.
Ms Taylor said: “Codie’s short period of stability sadly, as feared by her parents, was not to last long, and she was re-opened to services in May 2022.
“Episodes of dysregulation increased, leading to admission to hospital under the Mental Health Act in July, October, and December 2022.”
In January 2023, she had eight emergency admissions due to ‘incidents of serious self-harm which appeared to have been precipitated by the imminent release of the perpetrator of her abuse from prison’.
On January 22, 2023, she was admitted to the RVI in Newcastle following an overdose, and made two further attempts within 24 hours before being detained under the Mental Health Act, and transferred to the Carleton Clinic on January 23.
Ms Black was judged to be suffering from emotionally unstable personality disorder and post-traumatic stress disorder which could no longer be managed safely in the community.
She disclosed to staff that she had researched drowning as a means of ending her life.
Ms Black’s responsible clinician, consultant psychiatrist Dr Khadra, told the court that at a multi-disciplinary team meeting the following day, he had changed her observations from continuous to every ten minutes.
When questioned, he said that he did ‘not see the prospect of bathing as a main factor’, and it was important to give Ms Black ‘dignity and privacy’.
Ms Taylor summed up her questioning of Kelsey Morgan, who was on the ward from January 29 to 31.
She said that Ms Morgan ‘would have considered Codie’s records’, but ‘she did not however recall the entry about Codie having researched drowning’.
On the events of the morning of January 31, Ms Taylor commented: “She was aware that Codie had had an unsettled night, but during her very brief contact, she had felt she was settled.
“When approached by a healthcare assistant, who asked if Codie was allowed to have a bath, she agreed.
“She was not aware that Codie had been tearful that morning.
“The information that Codie had researched drowning was not considered by her.
“She was aware that Codie had ligatured but had not been concerned by her presentation that morning.
“She told me that she was aware that Codie had used baths previously to reduce stress, and that on previous occasions, they had gone without incident.
“She had not anticipated that face to face observations would take place while Codie was in the bath.
“She anticipated that these would be verbal through a closed door.
“”She accepted it would not be possible to illicit the information required by the observation and engagement policy without seeing the patient face to face.”
The healthcare assistant, when questioned, revealed it was her first week working on the ward, and her first day of performing observations.
She said that she had no access to patient records or information other than what she learned on handover of shifts.
She said she could not recall if Ms Morgan had asked her about Ms Black’s presentation when the bath was requested, nor could she recall being told how to observe, but said another staff member had told her she could do so verbally behind a closed door.
She said she had not been asked to check the bathroom before Ms Black entered, nor to check what Ms Black was taking into the bathroom with her.
She said that at 1.22pm, she elicited an initial verbal response when Ms Black was alone in the bathroom, but then when she came back, received no response.
Instead of entering herself, she sought another staff member, who entered around a minute later, finding Ms Black submerged in the bath, with clothes on.
Paramedics were called, and a faint heartbeat was detected, but despite attempts to revive her, Ms Black was pronounced deceased.
Ms Taylor identified ten specific areas of failure by the Trust, questioning the decision to allow Ms Black to have a bath.
She said: “The Trust’s position has been and remains that the decision was appropriate.
“I do not agree.
“The justification for depriving this young woman of her fundamental right to freedom was to manage and assess risk, a risk could not be safely managed within the community.
“It was incumbent on those responsible for her care to ensure that all her activity on the ward was assessed so that her safety was not compromised.
“I find that the absence of adequate risk assessment and the decision to allow Codie to take a bath was unsafe and more than minimally, negligibly, or trivially contributed to her death.”
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Turning to the failure to visually observe Ms Black while she was in the bathroom, Ms Taylor said: “It has been admitted by the Trust that the departure from the observation and engagement policy in this instance compromised Codie’s safety.
“When Codie was pulled from the bath, she was clothed, and it is reasonable to infer that had a visual check been undertaken as required, this would have led to an observation that she was dressed and action would have been taken to ensure that she did not remain in the room alone.
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“I find that the failure to conduct a face to face observation more than minimally contributed to her death.”
Ms Taylor made a conclusion of death by misadventure.
She said: “I have discounted suicide.
“Although often experiencing suicidal ideation, the nature of Codie’s illness customarily led her to self-harm as a means of release.
“Sadly, this always put her life at risk due to misadventure.
“While I cannot be certain, it is probable that the act of ligaturing left Codie in an incapacitated state and while in that state, she slipped under the water.
“Her incapacity left her unable to surface which would have been the reflex response of a conscious person.”
Finally, Ms Taylor criticised the Trust’s handling of the coronial process.
She said: “During the course of this inquest, I have heard on numerous occasions, the witnesses could not recall events or could not recall what they knew at the time of Codie’s death.
“I found this surprising.
“I would have found that given the enormity of what had happened on the ward on January 31, it would have been etched in the memories of all that were involved.
“I am concerned that very detailed statements were not immediately taken by the trust.
“A tragedy of this enormity requires detailed investigation at the earliest opportunity.
“This does not appear to have happened, and that in part has added to the distress of this family who have found it difficult to understand why evidence has not been presented in a timely manner.”
Ms Taylor acknowledged that since the time of Ms Black’s death, changes and improvements have been made to procedure, and she requested an update on this within 28 days.
Dr Rajesh Nadkarni, Executive Medical Director at Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, said: “Our thoughts are with Ms Black’s family and friends at this very difficult time.
“We will reflect on the conclusions drawn by the coroner.
“We will make sure that this happens in a timely manner and the lessons learnt will be used to improve our services.”