Latest news with #EliseSebastian
Yahoo
29-05-2025
- General
- Yahoo
Mum's promise to help end mental health deaths
A heartbroken mother said she would do "everything I can" to make sure the circumstances that led to her daughter's death were not repeated. Elise Sebastian was 16 when she was found unresponsive in her room at the St Aubyn Centre mental health unit in Colchester in April 2021. An inquest jury at Essex Coroner's Court concluded that "poorly administered observations" contributed to her death. Victoria Sebastian said she would be taking part in the ongoing Lampard Inquiry, which is investigating the deaths of more than 2,000 mental health patients in Essex. "I will be fighting with the inquiry and doing everything I possibly can to make sure, no matter how painful it is for me and my family, nobody else has to do this because it is heartbreaking," she said. The Essex Partnership University NHS Foundation Trust (EPUT) runs the unit, and chief executive Paul Scott apologised to Elise's family. Elise, a big Harry Potter and music lover, lived in Southminster near Maldon. She had been diagnosed with autism and her parents became increasingly concerned about her anxiety and depression, and in March 2021, she was admitted to the unit for a second time. The inquest heard she was supposed to be receiving one-to-one care, but on 17 April, she was left in her room for 28 minutes. Jurors were told how staff muted an audible alert that was part of a new infrared monitoring system, that had been installed in the unit two months previous. EPUT accepted the trust's failures were "causative of her death" and its lawyer Pravin Fernando said: "[It] failed in its responsibility by allowing her to enter her bedroom unsupervised." Speaking after the conclusion, Mrs Sebastian said her daughter was "dramatically and horrendously" failed and that she was treated as an "inconvenience" in the unit. "She was meant to be safe, but instead she was allowed to make several attempts to take her own life in the days leading up to her passing, until she finally succeeded," she continued. "There have been too many deaths. "It is the most painful thing ever to lose a child and I will do everything I can to make sure it doesn't happen to somebody else's child. "Lessons should have been learnt and I should still have had my beautiful baby girl." The Lampard Inquiry team has been monitoring the progress of the inquest. Mr Scott said: "I want to say sorry to Elise's family and to everyone who loved her that she did not receive the care she deserved, and I offer my deepest condolences." If you have been affected by this story or would like support then you can find organisations which offer help and information at the BBC Action Line. Follow Essex news on BBC Sounds, Facebook, Instagram and X. Neglect at unit led to teenager's death - inquest Alert muted before teen died at unit, inquest told NHS trust admits failures led to teenager's death Essex Partnership University NHS Foundation Trust
BBC News
29-05-2025
- General
- BBC News
Grieving Essex mother pledges to help end mental health deaths
A heartbroken mother said she would do "everything I can" to make sure the circumstances that led to her daughter's death were not Sebastian was 16 when she was found unresponsive in her room at the St Aubyn Centre mental health unit in Colchester in April inquest jury at Essex Coroner's Court concluded that "poorly administered observations" contributed to her Sebastian said she would be taking part in the ongoing Lampard Inquiry, which is investigating the deaths of more than 2,000 mental health patients in Essex. "I will be fighting with the inquiry and doing everything I possibly can to make sure, no matter how painful it is for me and my family, nobody else has to do this because it is heartbreaking," she Essex Partnership University NHS Foundation Trust (EPUT) runs the unit, and chief executive Paul Scott apologised to Elise's family. Elise, a big Harry Potter and music lover, lived in Southminster near had been diagnosed with autism and her parents became increasingly concerned about her anxiety and depression, and in March 2021, she was admitted to the unit for a second inquest heard she was supposed to be receiving one-to-one care, but on 17 April, she was left in her room for 28 were told how staff muted an audible alert that was part of a new infrared monitoring system, that had been installed in the unit two months accepted the trust's failures were "causative of her death" and its lawyer Pravin Fernando said: "[It] failed in its responsibility by allowing her to enter her bedroom unsupervised." Speaking after the conclusion, Mrs Sebastian said her daughter was "dramatically and horrendously" failed and that she was treated as an "inconvenience" in the unit."She was meant to be safe, but instead she was allowed to make several attempts to take her own life in the days leading up to her passing, until she finally succeeded," she continued."There have been too many deaths."It is the most painful thing ever to lose a child and I will do everything I can to make sure it doesn't happen to somebody else's child."Lessons should have been learnt and I should still have had my beautiful baby girl."The Lampard Inquiry team has been monitoring the progress of the Scott said: "I want to say sorry to Elise's family and to everyone who loved her that she did not receive the care she deserved, and I offer my deepest condolences."If you have been affected by this story or would like support then you can find organisations which offer help and information at the BBC Action Line. Follow Essex news on BBC Sounds, Facebook, Instagram and X.
BBC News
28-05-2025
- Health
- BBC News
EPUT: Neglect at mental health unit led to death of Elise
Neglect at a mental health unit contributed to the death of a "happy and outgoing" 16-year-old, an inquest jury has Sebastian, from Southminster near Maldon, Essex, was found unresponsive in her bedroom at the St Aubyn Centre in Colchester, in April teenager was supposed to have been receiving one-to-one care but, the inquest heard, an infrared alert system - which warned staff if she had been in her bathroom for too long - was muted, and she had been left alone for 28 inquest jury at Chelmsford Coroner's Court unanimously agreed that Elise's death could have been prevented if it were not for multiple failures in her care. The St Aubyn Centre, described in the hearing as "chaotic", is run by the Essex Partnership University NHS Foundation Trust (EPUT), currently the subject of an ongoing public Fernando, representing EPUT, admitted that Elise's room should have been locked to prevent the teenager entering alone, adding: "The trust accepts that these failings were causative of her death." The inquest heard Elise had secured a place at Writtle College to work with animals and her parents described her as a "happy, outgoing, funny little girl".She had been diagnosed with autism and her parents has become increasingly concerned about her anxiety and 4 March 2021, after she had self-harmed a number of times, she was admitted for the second time to a ward at the unit. 'Poor Wi-fi' Essex area coroner Sonia Hayes heard how Elise had asked to go to the toilet, and although some doors may have been left open, others needed a staff swipe card to let her ward had introduced an infrared monitoring system two months earlier as part of a trial, to reduce the risk of patients self-harming in isolated monitoring tablets were not working because of poor Wi-fi, and the unit's clinical lead, Brian O'Donnell, did not think having someone allocated to monitoring the alerts on the main computer would be a "good use of their time". During the inquest, expert witness Prof Jasmeet Soar said that when Elise was found, she had been in cardiac arrest for nine said there had been a four to five minute delay in staff using an oxygen mask, and a defibrillator took seven minutes for staff to use, instead of the three minute maximum mentioned in guidelines."Someone should have got the defibrillator and started it earlier," he Soar said the defibrillator also did not appear to have been used properly, from the readings he obtained, and had been switched on and said: "Some of the delays could have been avoided if staff would have known how to use the equipment." The inquest also heard how the majority of staff in the unit were bank and agency workers who would not have known the children Hayes said she heard the ward "was clearly short staffed" and described how medical records appeared to be incomplete at O'Donnell said he had "constantly" raised concerns about staffing numbers with senior management, adding: "Our budget would always be overspent - my argument was that we were underfunded."The inquest heard how observations should have a therapeutic interaction but some thought that was impossible to child and adolescent psychiatrist Dr Malcolm Bourne also told the hearing that "staff needed support to deal with children who were challenging and that autism could make depression more difficult to treat". Shortly after Elise's death, the ward at the St Aubyn Centre was closed to new admissions by the Care Quality CQC report found understaffing was a "significant concern" made worse by managers not ensuring staff had the appropriate skills and experience to look after vulnerable patients. 'Deepest condolences' The jury foreman told the inquest there were two main factors that may have caused the teenager's first was "poorly administered observations due to poor staffing levels and falsified information on observation forms".He said the second was "Elise being able to gain access into her room and her observation level in an isolated area not being considered", which the jury believed had directly led to Elise's death. The coroner said she would write a prevention of future death report (PFDR) which would recommend changes to make sure failures were not Scott, chief executive of EPUT, said: "I want to say sorry to Elise's family and to everyone who loved her that she did not receive the care she deserved, and I offer my deepest condolences." Follow Essex news on BBC Sounds, Facebook, Instagram and X.
BBC News
09-05-2025
- Health
- BBC News
Elise Sebastian's inquest: 'We were short-staffed', NHS boss says
A clinical director criticised staff shortages and NHS budgets at an inquest into the death of a teenager at a mental health Sebastian was 16 years old when she was found unresponsive in her bedroom at the St Aubyn Centre, Colchester, in April the inquest, Brian O'Donnell, clinical lead at the centre, told the jury he had "constantly" raised concerns about staffing numbers with senior management."Our budget would always be overspent - my argument was that we were underfunded", Mr O'Donnell Essex Partnership University NHS Foundation Trust (EPUT), which runs the centre, said it should not have let her in the room unsupervised. 'Bad habits' The inquest previously heard that Elise was supposed to receive one-to-one care, but an alert system - linked with her bedroom - was muted and she was left alone for 28 O'Donnell, who was the ward manager at the time, told the jury how staff were being asked on occasions to check as many as 15 patients with less than a minute to speak to each one."Looking back, it's unbelievable that we used to do that", he told the jury, referring to it as a "tick-box exercise" where staff would look at a patient quickly and "move on".Mr O'Donnell said staff were meant to randomise the times they checked on patients but often did not do so, "pre-populating" the patient's observation sheet with timings."People had got into a bad habit of doing it over the years - it was a very bad ingrained piece of practice", Mr O'Donnell added that he had written 56 letters to individual members of staff about not recording observations properly, but "no matter what I did, there always seemed to be gaps".He added that the practice continued "even to this day".The clinical director said on other occasions, the patients on the ward had not been checked for hours, which left him so concerned that he reported it to the Care Quality Commission on three occasions. Mr O'Donnell said the over-reliance on using agency and bank staff to cover staff shortages was "a risky strategy", and added that patients would push the boundaries with them."If a young person is intent on harming themselves, they'll pick weaknesses in a team," he told the inquest."They'll ask staff for something they know they shouldn't have until they find someone who'll let them have [it], or take them somewhere they're not meant to go."He added: "Even the best agency or bank staff don't know the ward like we do." 'People in tears' When asked by the area coroner, Sonia Hayes, about staffing levels, Mr O'Donnell said "the trust do look at the bare minimum that you need to cover observations - it really stretches staff"."I've seen huge pressure on people - I've seen people in tears before," he told the jury, adding there was "real concern about safety on the wards, and staff are too worried to say anything about it". Elise died in hospital two days after being found in her bedroom at the accepted its failures were "causative of [Elise's] death", and its lawyer, Pravin Fernando, said: "[It] failed in its responsibility by allowing her to enter her bedroom unsupervised."Elise's family attended the first day of her inquest and were participating in the ongoing Lampard public inquiry, which is investigating the deaths of more than 2,000 people under mental health services in Essex over 24 Lampard Inquiry team will monitor Ms Sebastian's inquest, which is due to last for four weeks. Follow Essex news on BBC Sounds, Facebook, Instagram and X.
Yahoo
01-05-2025
- Health
- Yahoo
Alert muted before teen died at unit, inquest told
Staff muted a safety alarm before a teenager was found unconscious at an NHS mental health unit, an inquest heard. Elise Sebastian died in April 2021 after she was found unresponsive in her bedroom at the St Aubyn Centre in Colchester. The 16-year-old was supposed to receive one-to-one care but an inquest was told an alert system, linked with her bedroom, was muted and she was left alone for 28 minutes. The coroner was told changes had been made to the alert system. The unit is run by the Essex Partnership University NHS Foundation Trust (EPUT), which is the subject of an ongoing public inquiry. Elise, who was from Southminster near Maldon, was found unresponsive in her room on 17 April 2021. She died in hospital two days later. The alert system, called Oxyvision, was introduced in the ward two months beforehand. The inquest was told the system was designed to help staff monitor the safety of patients in their bedrooms and bathrooms by using infrared sensors, and to reduce the number of self-harming incidents. Essex area coroner Sonia Hayes read from a patient safety investigation conducted by EPUT following Elise's death. It said that "confidence had been weakened" in the system because the wi-fi was not reliable on the mobile tablets used by staff. An alarm would usually sound on the tablets if a patient was where they should not be. The report also found an alert on a desktop computer in the nurse's office was muted. It said this "led to a considerable reduction in the line of sight to Elise's bedroom". The coroner was told it was the trust's policy to raise a Datix safety report if the wi-fi was not working properly, but no report could be found. The inquest jury was told - that the day after she died - the trust changed its operating procedure, telling staff the volume on alerts must not be turned down or muted. Laura Cozens is head of patient safety and quality at Oxyhealth, which provides the Oxyvision system. She said the tablet software had since been tweaked, so that the volume of the alert automatically rose after 60 seconds of sounding. The system was an "additional supportive tool and it shouldn't replace staff", she added. Brian O'Donnell, clinical lead for EPUT, told the jury that signs had been placed around the main computer terminal asking staff not to turn down the alert volume. He said warnings and alerts should never be ignored, adding he "would absolutely not expect any staff member to mute the volume". Mr O'Donnell was asked if staff had muted it so they were not disturbed. "I wasn't there, so I don't know," he added. He admitted that since Oxyvision was installed, there had been some complacency. "We do rely too much on technology nowadays," he said. The inquest continues. Follow Essex news on BBC Sounds, Facebook, Instagram and X. NHS trust admits failures led to teenager's death Essex Coroner's Service
