Woman’s death at mental health hospital was avoidable

Organisations we investigated: 2gether NHS Foundation Trust and Glouscestershire Hospitals NHS Foundation Trust

Date investigation closed: 14 November 2019

The complaint

Mrs J complained about the care and treatment that her sister, Miss L received at the trusts in November 2015. She said that the trusts failed to act on the increasing frequency of her sister’s epileptics seizures and attempts to take her own life, and that Miss L was not observed continually as she should have been.

Mrs J also complained about the Trust’s handling of her complaint.

What we found

We found that the trusts failed to:

  • observe Miss L in line with national guidelines
  • act on the consultant psychiatrist’s call for a review of medication
  • escalate Miss L’s risk of self harm from moderate to severe.

If these failings had not occurred, it is likely that Miss L would have been less likely to take her own life, and any attempt to do so would likely have been prevented. In these circumstances she would have been observed on a continual basis, her medication would have been reviewed, and the deterioration of her condition would have been noted and acted upon with sufficient urgency. We found that on the balance of probabilities, her final attempt to take her own life would not have occurred, and it is more likely than not that her death would have been avoided.


Miss L was a long-term mental health patient at the 2gether NHS Foundation Trust. She suffered from depression, schizophrenia and epileptic seizures. This complicated her treatment, as many epilepsy drugs can have the side effect of causing depression, and some antipsychotic medication can make epileptic seizures more likely. Miss L’s condition was managed by the Gloucestershire Hospitals NHS Foundation Trust.

After some time in the psychiatric intensive care unit, Miss L was returned to her usual ward on 5 April 2016. She subsequently attempted to take her own life on 9, 14 and 16 April. Between 5 and 16 April she also suffered a number of epileptic seizures, which she said she was finding increasingly difficult to cope with, and had influenced her increasing attempts to take her own life. On 17 April, Miss L was found unresponsive after another attempt to take her own life. She sadly died on 5 May after never having regained consciousness.

Putting it right

We recommended that the trusts write to Mrs J to acknowledge the failings we identified in her sister’s care, and apologise for the impact they have had on her. The trusts should produce action plans to explain how they will ensure that similar failings do not occur in the future. We also recommended that the trusts make a payment to Mrs J, in recognition of the injustice she suffered as a result of their failings.

This case summary is featured in the Ombudsman's Casework Report 2019.