Mother’s death at NHS mental health unit was third in 15 months, sparking calls for reform

Sign up for our free Health Check email to receive exclusive analysis on the week in health Get our free Health Check email Please enter a valid email address Please enter a valid email address SIGN UP I would like to be emailed about offers, events and updates from The Independent. At the inquest, Oxford Health said the prospect of discharge was used to make Emma engage with treatment and she would not have been discharged while still unwell, the family’s solicitor’s Leigh Day said. “If a patient hits a point of crisis and actually there is no one there, that can obviously lead to really serious incidents.” The inquest jury found that multiple failings had occurred and concluded it was possible Emma’s care and discharge planning “contributed in more than a minimal or trivial way to her death”. “They obviously haven’t made the right changes or got their act together to save our girl, and the young girl.” There were also repeated issues around Whiteleaf’s communication with family members, highlighted in all three inquests – and recognised as an issue nationally in a major independent review of the Mental Health Act published last week. “Inquest has consistently called for a national body responsible for overseeing learning to prevent unnecessary deaths from failed learning.” A spokesperson for Oxford Health NHS Foundation Trust said it had taken note of the jury findings, and had commissioned its own review of the circumstances around Emma’s death.