The parents of a woman who ‘brought light and laughter’ to the lives of all who knew her have told of the devastation of losing their daughter just weeks into her stay at a mental health hospital.
Leah Taylor, 20, from Urmston was admitted to Eleanor Hospital in West Didsbury on May 24 last year and detained under Section three of the Mental Health Act, a jury inquest into her death at Manchester Coroner’s Court heard.
Less than a month later, in the early hours of June 17, she was found unresponsive in her bedroom and tragically pronounced dead by paramedics. At the time Leah was being monitored four times an hour by staff.
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On the first day of the inquest into her death on Monday (May 20) coroner Zak Golombeck told the jury that one of the issues he wanted the jury to focus on was whether Leah should have been placed on constant one-to-one observations in the period leading up to her death.
In a summary of the case he told the jury there had been ‘multiple incidents’ of deliberate self harm involving Leah during her stay at Eleanor Hospital, including eight incidents on the day before her death.
Eleanor hospital, run by Equilibrium Healthcare, provides care for women who have been diagnosed with a personality disorder or mental illness.
In 2022 Eleanor Hospital was rated 'inadequate' following an inspection by the Care Quality Commission (CQC) in May of that year and placed in special measures.
Following an inspection on June 20, 2023, three days after Leah’s death, the service was again rated ‘inadequate’.
Paying tribute to their daughter previously, parents Paul and Helen described her as ‘bubbly’ and said she was 'so talented in making people smile'.
In a moving pen portrait read to the inquest, they said that although their daughter had ‘struggled’ with her mental health for many years she was a ‘determined young woman’ who had dreams of becoming a special educational needs (SEN) teacher and plans to travel.
They described Leah as a ‘sensitive soul’ with a ‘heart of gold’ who would ‘help and support’ others in any way she could, adding her weakness may have been that she ‘cared too much’.
Paul and Helen said Leah was ‘ridiculously funny’ with an ‘off the wall sense of humour’ and an ‘army of friends' who adored her.
They added: “Leah brought so much love and laughter into all our lives. She was an inspiration, and she has left a permanent mark on all that knew her.
"She was a gift that kept on giving, she truly was one of a kind. Leah was our light and our only focus in life. We were a team, a team of three people who adored each other. Now she is missing, our light has gone out."
In a separate statement read to the inquest, Paul said he believed there were ‘numerous missed opportunities incorrect decisions, poor judgement, and a lack of knowledge on how to support Leah during her stay at Eleanor Hospital', adding: “We believe Leah would still be alive if the correct actions had been taken”.
Paul said he and Helen ‘never received updates’ on Leah’s progress or decline whilst she was at Eleanor Hospital and were not made aware of any of the many incidents involving her.
Paul said they only learnt of the incidents involving Leah on June 16, the day before her death, in documents weeks after her passing.
He added: "If we had been truthfully updated about Leah’s progress and, in particular, informed of the incidents that occurred on June 16, we would have been able to discuss with staff how to support Leah to de-escalate in these situations. We would have also attended the hospital in person to see Leah."
Paul said Helen received a call from Leah on the evening of June 16 and that she seemed ‘extremely distressed’. Paul said he immediately called the hospital and that ‘at no point in the call’ was he told of any incidents involving Leah.
He said he later called Leah and she seemed more ‘settled’ and ended the call by saying to to him: ‘Night dad I love you, see you tomorrow’. It would be the last time he would speak to her.
Paul said when reviewing documentation later sent to him he found out Leah had ‘assaulted’ a member of staff’ on June 16 and that she was told the incident had been reported to the police. He said this would have caused Leah 'great distress' and that it was noted in Leah’s records how she reacts to police matters, and how it was a 'trigger' for her.
Giving evidence, Leah’s clinician and the group medical director of Equilibrium Healthcare, Dr Sholinghur said Leah had been diagnosed with emotionally unstable personality disorder and ADHD. The inquest later heard Leah thought her emotions were ‘all over the place’ and she ‘couldn’t control it’.
Dr Sholinghur said Leah was on level two observations throughout her stay at Eleanor Hospital, meaning she was observed four times an hour, and confirmed her observations were never increased to constant one-to-one observations which would have seen her kept within staff’s eyesight at all times.
The inquest heard that within 24 hours of Leah’s admission there had been multiple incidents of deliberate self harm, including two ligature incidents.
Asked by coroner Golombeck whether he was ‘concerned’ by that, Dr Sholinghur said the incidents may have been caused by the ‘stress of a new place’ and that it was up to the team at the hospital to ‘manage’ them and ‘help’ the patient.
On June 8 the inquest heard Dr Sholinghur saw Leah during a ward round and was aware of four self-harm incidents involving her, on June 3, including attempts to ingest foreign objects. He said in light of the incidents he made the decision to keep Leah on level two observations to provide ‘close monitoring and support’.
He added that he was not made aware of a further incident on the evening of June 3, that saw Leah fill a bath and express an intention to drown herself.
Dr Sholinghur said that based on the four incidents on June 3 that he was made aware of there was ‘no rationale’ to increase Leah’s observations and her actions ‘did not warrant’ a higher level of observation.
The inquest heard that in the days following June 3 there were no incidents involving Leah. Dr Sholinghur said Leah appeared to be ‘settling into the ward’ and ‘getting to know staff’.
He added that there was since ‘lack of engagement from Leah’ but also ‘episodes of her trying to engage’.
The inquest heard a further ward round was scheduled for June 22 and that they were normally held every two weeks.
Proceeding
