Neglect by mental health hospital staff involved in the care of a patient from Mapperley contributed to her death at the age of 22, the jury at her inquest has found.

Sophie Towle died after suffering a blood clot at Sherwood Oaks Hospital in Mansfield, run by Nottinghamshire Healthcare NHS Foundation Trust, on May 27, 2024.

At the end of the emotional three-week hearing into her death today, October 24, the jury delivered their damning verdict that a litany of failures by the hospitals overseeing her in the months before her death probably played a part in her passing.

Sophie had been in and out of mental health facilities since 2021.

When she was last sectioned in late 2023, she was situated at a mental health facility in Doncaster due to a lack of beds in Nottinghamshire.

She found the experience much better than when she’d stayed at other hospitals run by Nottinghamshire Healthcare NHS Foundation Trust in the past and believed she was making progress with her mental health.

But on April 24, 2024, she was transferred back to Sherwood Oaks.

The jury found that there was “no clinical rationale” to move her back, and agreed with the Rotherham, Doncaster & South Humber NHS Foundation Trust’s admission that co-ordination between themselves and the family regarding her repatriation was poor.

The move back “destabilised” her, and made her upset due to the lack of preparation time for it, the jury found.

When she got there, there was no body mapping done, no wound care done, no assessment care plan made, no weight management care plan made, no reassessment of her blood clot risk and an inconsistent care plan with regards to her physical observations.

Two weeks later, on May 12, Sophie self-harmed by sticking the plastic ink container of a biro pen into an open wound on her left leg – while on 24/7 observations with a healthcare assistant sitting in the doorway watching her.

The jury found that staff member Egbejimba Remi Henry’s observation was inadequate and not in accordance with policy.

Afterward, Sophie was taken to King’s Mill Hospital in Mansfield and returned on the following two days, but the decision was ultimately made not to remove the pen due to clinical reasons.

Her wound then became painful, meaning she couldn’t walk, and later infected.

On May 27, Sophie complained of chest pains and that she felt unwell.

At 5.50pm that evening, while in the communal area of Fir Ward at Sherwood Oaks Hospital where she stayed, she suffered a seizure and was taken to hospital.

She later collapsed in cardiac arrest.

Her cause of death was recorded by the jury as pulmonary thrombolism of the lungs, secondary to a deep vein thrombosis in her left leg, which was probably caused by a combination of her obesity and the reduced mobility she had suffered after the pen incident.

The jury found that Sophie’s immobility and her wound becoming infected likely played a part in the formation of the blood clot that eventually killed her, and that the inadequate observation on May 12 more than minimally contributed to the immobility and the infection, due to them being a direct result of the pen being inserted.

The jury also found that Sophie’s care was ‘substandard’ due to staffing levels and a lack of staff experience, with a reliance on bank staff who didn’t necessarily know Sophie.

There was no continuity of care and a lack of policy awareness and compliance.

They agreed with Sherwood Oaks’ admission that they failed to see the need to assess Sophie’s blood clot risk, as well as that they had no formal care plan for managing Sophie’s obesity or monitoring her leg wound.

Health checks on Sophie were also not done in accordance with a care plan.

Concluding, the jury foreperson told the coroner that as well as the aforementioned contributions to her death, Sophie’s hospital transfer, her risk assessments in relation to her access to harmful items, her lack of blood clot risk assessment and the failure to note the fact or significance of her lack of mobility all probably more than minimally contributed to her death.

Also listed as a probable contribution was the information sharing between King’s Mill Hospital and Sherwood Oaks regarding Sophie’s presentation.

Sophie’s parents Jeremy and Leisa, who had been present for every day of the inquest, burst into tears as the verdict of neglect was read out.

Assistant Coroner Alexandra Pountney said she would issue a Prevention of Future Deaths Report to Nottinghamshire Healthcare and Sherwood Forest Hospitals Foundation Trust.

The report will cover “a lack of joined-up thinking in relation to liaison between physical and mental health professionals,” the coroner said, as well as Nottinghamshire Healthcare’s blood clot policy and staff’s understanding of it, and concerns over the disbanding of the trust’s Personality Disorder Hub.

For Sherwood Forest Hospitals Trust, which runs King’s Mill Hospital, it was concerned with its policy of removing foreign objects.