When Sophie Towle was in the taxi taking her back to Sherwood Oaks Hospital, she texted her parents her funeral arrangements.
Four weeks later, she died aged 22.
“Mum, I don’t feel safe here,” reads a message to her mother, Leisa, from that short time.
At the end of Sophie’s three-week inquest on October 24, a twelve-person jury, who debated for just a few hours, found that neglect by those caring for her had contributed to her death.
Sophie was sectioned under Section 3 of the Mental Health Act when she died, meaning Sherwood Oaks Hospital, run by Nottinghamshire Healthcare NHS Foundation Trust (NHCT), was legally responsible for looking after her.
When the jury’s conclusion was announced in court, Leisa and Sophie’s dad Jeremy burst into tears.
At first sight, it seemed they were tears of pain. But really, they were mostly tears of relief.
“We’d been heard,” said Leisa. “Sophie had finally been heard. People can see what she and we went through. My worst nightmare would have been getting to the end of the inquest and it being ruled as natural causes or unpreventable.
“We always thought it could’ve been prevented, but for other people who didn’t know us to come to the same conclusions, it was a relief. We were right.”
Sophie’s story
Sophie’s mental health problems had originated in her youth and became worse in her teenage years.
In 2021, she sought a diagnosis for ADHD, which she received.
In the same session, when being screened for other potential issues, she was found to have EUPD – Emotionally Unstable Personality Disorder, sometimes known as Borderline Personality Disorder (BPD).
In September that year, she was sectioned for the first time at Highbury Hospital in Nottingham, another NHCT facility, where she had a traumatic stay.
Sophie was later discharged into the community and lived on her own in a supported living flat in West Bridgford.
When she was sectioned again in May 2023, she was taken to Sherwood Oaks, where she found her experience equally as bad.
She spent more periods in and out of hospital, including another stint at Highbury, before being taken to Doncaster’s Tickhill Road Hospital in the autumn of 2023.
Suddenly, she started to make progress. Sophie’s parents were really pleased.
“She had a sleeping pattern for the first time in years,” says Leisa. “She felt safer.”
“I found it enjoyable to visit her. Not like Sherwood Oaks, which was intimidating,” adds Jeremy. “In Doncaster, you saw the same nurse every week.”
But on April 24, 2024, a month before she died, a taxi arrived to pick her up and transfer her to Sherwood Oaks.
The family had known there were plans, but not that it would happen without warning.
Sophie tried to resist going, but would have been forcibly moved by police if she didn’t.
“In court, they kept calling the move ‘destabilising’,” says Leisa. “Actually it was catastrophic.”
Back in Nottinghamshire, Sophie’s mental health took a turn for the worse.
On May 12, she self-harmed. She had been on 24/7 observations at the time – designed so she didn’t have a chance to do something like that.
The pain that resulted led to her being unable to walk and she spent the ensuing days stationary, which eventually caused a blood clot to form in her leg.
This moved up to her lung and caused a massive pulmonary embolism.
She died on May 27, 2024.
The inquest
The fact that Sophie was in the state’s care at the time of her death is what led to a jury being involved.
The inquest heard from numerous witnesses involved in her care, including those in Doncaster, at Sherwood Oaks Hospital and at King’s Mill Hospital in Mansfield, where Sophie was treated after the self-harming incident.
At the end, some of the jury were in tears.
“We were just in shock at how badly some people did their job,” says Leisa about the evidence they heard.
Ultimately, because Sophie’s care wasn’t in her parents’ hands, they could do nothing but watch as other people failed to look after her properly.
“We’re angry,” says Jeremy. “Disappointed and frustrated.”
“For that month she was in Sherwood Oaks, it’s so hard to think of how she felt so let down, and how that emotional pain was just enormous, and I couldn’t take that away,” adds Leisa.
“Sometimes I had got to the point where, because Sophie had been in such crisis, I did wonder if maybe it was better if she was free of it. She’s not experiencing that emotional pain now. So is that better?
“But then she didn’t get the opportunity to push on from Doncaster which might have made her better.”
“We’ll never know,” says Jeremy.
‘I don’t want closure. Closure to me means final’
It’s been nearly 18 months since she died. Today, Saturday, November 15, is Sophie’s birthday; she would have been 24.
Despite the passage of time, the grief is still real for Leisa and Jeremy.
“We’re just continually exhausted,” says Leisa. “I never realised how much stress affects your body. Aches and pains and illnesses. It’s just incredible. It’s a rollercoaster of emotions. I can feel myself getting very emotional because her birthday’s coming.
“They say it’s all the firsts. But I don’t think it’s just the firsts. It’s the seconds and the thirds. Every family gathering, there’s somebody missing.”
Around the family home in Mapperley, Sophie’s stuff is still everywhere – her hairbrush, cuddly toys, boxes of clothes. Her ashes are in an urn on the mantelpiece.
Leisa still lights a candle every day for Sophie, and says goodnight to her when she goes to bed.
And while the inquest was a victory, the job isn’t over, says Leisa.
Her focus now is on creating her daughter’s legacy.
“Everybody said, oh, when you’ve had the inquest, you’ll have closure,” says Leisa. “But I never want closure.
“Closure to me means final. And I never want that to be final. I want to keep fighting for Sophie and for people like her.”
Next week, she’s going up to Teesside to meet the parents of Chris Irish, who died by suicide in 2021.
They’ve been successful in creating an anti-suicide campaign in Chris’ name, and liaison officers at Nottinghamshire Healthcare suggested Leisa get some advice from them.
In the future, she has agreed to be present at staff inductions at the trust’s hospitals to tell them first-hand how important their jobs are.
While Jeremy’s anger remains, Leisa believes the trust, which had such a part to play in her daughter’s death, does want to improve, and her feelings towards them are not all bad.
“I have hope. I think there are people in NHCT that are trying to make a difference and I’m anxious that there are really good people out there. Nobody went out to kill her. They do seem to be very keen for us to be involved in making improvements.
“But how much of this is a culture? A culture is so much harder to change.”
‘Horribly, horribly painful’
Leisa also wants people to know more about Emotionally Unstable Personality Disorder.
People with the condition experience pain, similar to how others feel when they lose a loved one, almost daily over super minor things such as not receiving a text back after saying “I love you” or being blamed for something they didn’t do.
It isn’t treated with medication, only through psychology, which can take a long time.
The condition can mean those affected experience severe mood swings – sometimes several times per hour.
“Borderline Personality Disorder [as it’s also known] is horribly, horribly painful,” Leisa reads. “The intensity of emotion people with it feel, I can’t even imagine living with.”
Despite the symptoms, people with EUPD are not and often present as if they don’t have the condition.
Sophie was just “a normal girl”, say her parents. She was a Brownie leader, enjoyed cooking, and liked playing practical jokes.
One involved leaving miniature ornamental ducks around the hospitals she stayed in – to the bewilderment of staff.
At the inquest, Leisa passed every attendee one of these ducks as a memento of her daughter.
Sophie also loved theatre and saw many plays when she wasn’t in hospital.
There is now a plaque in her memory on the back of one of the seats at the Theatre Royal in Nottingham.
Back in Mapperley, a tree is dedicated to Sophie in the front garden. There is a plaque with her name on it and a photograph.
“People ask: ‘How do you carry on?’” says Leisa.
“We say we didn’t get a choice. My mind is screaming inside. Sometimes I just want to sit here and sob. But you do. You carry on.”
What the hospitals said
At the end of the inquest, the coroner issued a “Prevention of Future Deaths Report” to Nottinghamshire Healthcare NHS Foundation Trust and to Sherwood Forest Hospitals NHS Foundation Trust.
She believed that unless changes are made at the trusts, more people could die.
Ifti Majid, chief executive of Nottinghamshire Healthcare NHS Foundation Trust, said: “On behalf of the trust, I once again extend our sincere condolences to Sophie’s family and friends.
“We fully accept that there were aspects of care which were not of the quality Sophie deserved and for that we are deeply sorry.
“We have taken significant steps to improve, including the introduction of mandatory, comprehensive training for staff, which has led to improved compliance with Venous Thromboembolism (VTE) risk assessments.
“Our inpatient services now operate under a robust staffing framework supported by a nationally recognised tool. Staffing requirements are reviewed daily, and we take action to address any shortfalls such as redeploying staff or using bank staff.
“We recognise that patient needs on acute inpatient mental health wards can fluctuate, and unexpected events may arise that require additional support. To address this, we have formal reporting mechanisms in place to flag and respond to any concerns about staffing.
“We remain committed to ongoing improvement and will continue working closely with Sophie’s family and our hospital partners to drive meaningful change.
“A formal response to the coroner is due by the end of December, detailing how we are addressing the issues raised. This will be shared with Sophie’s family prior to its public release, so we will refrain from further comment on the specifics until that time.”
Dr Simon Roe, Chief Medical Officer at Sherwood Forest Hospitals, said: “I’d like to express my deepest condolences to Sophie’s family.
“As a trust, we are committed to providing outstanding care to all our patients and we are carefully considering the coroner’s comments to help improve the care we provide in the future.
“We are reviewing our policy relating to the management of insertion of foreign objects and working with colleagues at Nottinghamshire Healthcare NHS Foundation Trust to review and improve communications between our organisations.”
Rotherham, Doncaster and South Humber NHS Foundation Trust, which was the catalyst in Sophie’s transfer back to Sherwood Oaks, was also asked to comment.
