UK Inquiry Tracker

Lauren Bridges

PFD Report Historic (No Identified Response) Ref: 2023-0466

Date of Report 19 September 2023

Coroner Andrew Bridgman

Coroner Area Manchester South

Response Deadline est. 24 January 2024

Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

Coroner's Concerns (AI summary)

The Hospital Overview was not updated promptly or correctly, and crucial discussions about patient repatriation to an available bed were not documented.

View full coroner's concerns

a) the omission to update the Hospital Overview timeously and correctly.

b) it can be inferred from the absence of any documentation regarding discussions about Lauren’s repatriation to an available bed that no such discussion took place.

Part of a Series

2 separate reports were issued from this inquest, each sent to different organisations.

2023-0438
Sent to: Department of Health and Social CareNHS England

All responded

This report (2023-0466) is shown above.

Sent To

Dorset Healthcare University NHS Foundation Trust

Response Status

Linked responses 0 of 1

56-Day Deadline 24 Jan 2024

About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Report Sections

Investigation and Inquest

On 01.03.22 an investigation commenced into the death of Lauren Elizabeth Bridges who died on 26.02.22, aged 20 years. The inquest concluded on 01.09.23. The medical cause of death was 1a) Hypoxic brain injury 1b) Cardiac arrest 1c) Hanging injury The conclusion of the jury was Lauren Elizabeth Bridges ended her life by ligature. This was misadventure with Lauren not intending to commit suicide. Missed opportunities for moving Lauren closer to home with acute and PICU beds available during significant periods between July 2021 and February 2022 at St. Ann's, Seaview and Haven wards, contributed to increased incidents and her death. The prolonged stay in a PICU placement in Priory Cheadle led to iatrogenic deterioration. This was prolonged by a delayed discharge. There was inadequate communication about Lauren from Dorset Healthcare NHS Trust to relevant parties, and there was insufficient communication about Lauren from Priory Cheadle to relevant parties. Dorset Healthcare NHS Trust did not recognise the exceptional circumstances of the effects on Lauren being in an out-of-area placement over 260 miles away from home.

Circumstances of the Death

Lauren lived in Bournemouth. From March 2020 Lauren had been an in-patient, detained under section 3 of the Mental Health Act 1983. In January 21 Lauren was admitted to a Rehabilitation Unit, at The Priory, Dorking, as an Out-of Area patient. This placement was commissioned by Dorset CCG (as it was then – now Dorset ICB). Dorking is just over 100 miles from Bournemouth. In about mid-June 2021 Lauren’s mental health deteriorated and it was determined on 01.07.21 that Lauren needed to be transferred to a Psychiatric Intensive Care Unit to keep her safe. On 23.07.21 Lauren was transferred to Pankhurst Ward PICU, The Priory, Cheadle. Again, Lauren was an Out-of-Area patient at a distance, now, of some 260 miles from home. This placement was commissioned by Dorset Healthcare NHS Trust. Lauren was ready for step-down from the PICU by 02.09.21. The plan being to seek an acute bed, at or closer to home, while a suitable Rehabilitation Unit was found. Lauren remained in the PICU, at The Priory, Cheadle for the next 5 months, until her death on 26.02.22 following a ligaturing incident on 24.02.22. Over that time Lauren’s mental health deteriorated, with an increasing number of incidents of self-harm. A major factor in Lauren’s deterioration was the distance from her home and family.