On Wednesday, Melissa’s parents gave emotional testimony to the Coroner and the jury about their “impish” eldest daughter, who they miss dearly and who they described as a charming, caring young woman who lit up the room and had a love for life. They told the court that they had done all they could to understand their daughter’s eating disorder. They had seen firsthand how the disease had taken its toll on Melissa’s life. Their daughter didn’t believe she was worthy of getting better, and hospital admissions in adolescence – intended to understand and address Melissa’s low self-esteem and anorexic behaviours – only ended up traumatising her.

Melissa’s parents tried to persuade her to engage with her outpatient therapy appointments but, when doctors told them that Melissa’s food intake and potassium levels were so low that they were ‘life threatening’, they reluctantly accepted medical advice that another hospital admission was in her best interests. Believing Melissa would be safe in a specialist eating disorder service they accompanied their daughter to the Vincent Square Eating Disorder Service, or VSEDS, on 7 June 2021.

In spite of what follows, Melissa’s family are keen to emphasise that there are excellent, genuinely caring staff at VSEDS and that they would not want other young people in desperate need of help to be deterred from accessing services at VSEDS because of what happened to Melissa.

The court heard from numerous professional witnesses about Melissa’s own terror at the prospect of being detained in hospital again. In the ambulance, she admitted to paramedics that she’d secretly had some vodka to calm her nerves. The paramedics managed to perk Melissa up a little and get her chatting.

On arrival at VSEDS, Melissa’s ‘mood plummeted’ when the admitting doctor informed her that she couldn’t have a cigarette – an important coping mechanism, when all other comforts were no longer available.

Throughout this time, Melissa’s parents were telling the admitting doctor everything they could to help VSEDS staff keep their daughter safe. Melissa’s life was already in danger from low potassium and food intake. Adding to this the fact that she had a history of self-harming to process difficult emotions, had taken overdoses in the past to cope with grief (including whilst admitted to psychiatric hospital), that she had had a drink just that afternoon, and because she was visibly terrified and trying to escape the hospital, Melissa’s parents assumed that a close eye would be kept on their daughter at least in the first 72 hours of her admission. Not only had this always been the practice of other NHS Trusts, but it seemed so obvious to them that Melissa needed closer monitoring this time.

Having explained all of this to the admitting doctor, Melissa’s parents turned their attention to helping their daughter settle into her new room. The nurses were busy with a ‘property check’, during which various contraband items were removed to keep Melissa safe. Melissa’s father described the process as ‘superficial’. Key items were missed, including the item  that Melissa used to end her life.

Melissa’s mother noticed that her daughter had gone missing during the property check. She went to look for Melissa, and found her hugging herself and swaying by the doors of the ward – murmuring to herself ‘I can’t do this’ over and over again. Her mother asked her Primary Nurse for help, but was told that she was still busy with the property check. Eventually, her mother cried out to anyone who would listen. A nurse appeared, and managed to gently bring Melissa back to her room.

Noticing that it was almost mealtime – a difficult time for Melissa – and wondering whether their presence on the ward was dissuading Melissa’s Primary Nurse from getting to know her, Melissa’s parents took the difficult decision to leave VSEDS. In his evidential summing up, the Coroner reflected that no parent would want to leave their child in the circumstances Melissa was in. They were on the Tube home, when Melissa’s parents received a phone call from her consultant asking them to attend A&E, where Melissa had been taken after she became unconscious following an attempt at self-hanging in her room. She did not regain consciousness. After three years of hospital and hospice care, Melissa sadly passed away on 13 July 2021 as a result of the injuries she sustained on the day she was admitted to VSEDS.

What Melissa’s family have learned in the course of this inquest is that, after they left, the Primary Nurse didn’t engage their daughter in conversation – as they hoped she would. Unbeknownst to them, Melissa had been placed on ‘intermittent observations’ – meaning she was only being checked by nurses four times every hour. This gave Melissa enough time alone in her bedroom to self-harm one last time, unseen. Melissa then hanged herself from what should have been an anti-ligature point in her bedroom.

The court heard how, 3 months before Melissa’s admission to VSEDS, the ligature risk assessment team – which included the VSEDS Ward Manager – identified the potential for this to become a risk item through mechanical failure. The jury found that this mechanical failure in Melissa’s room  “should have been identified and managed” and that “the failure to identify the ligature point was, to a very significant extent, a probable cause of Melissa’s death”. The jury heard that there was little, if any, indication that Melissa intended to end her life. They were given the opportunity to consider a conclusion of “suicide” but instead recorded “misadventure”.

Melissa’s mother said:

Our beautiful, mischievous,, complicated, caring daughter died aged 27, although in reality, to everyone who knew and loved her, our Melissa died 3 years earlier. She had her whole life ahead of her; she had plans and dreams which included completing her psychology degree and working in Barcelona for a year. All of this potential and hope was taken away from her when the very place that should have helped her, allowed her to die unnecessarily.  She was loved by and important to so many people, whose ongoing support in the last 3 years of her altered life meant so much to us all. We also remain truly grateful for the excellent and loving care she received from the staff at Wilsmere Care Home. We did not just lose a loving daughter and sister we also lost the possibility of all of her tomorrows; as a bride, a mother, an aunt but mostly as a happy, fulfilled, contented person. without her in our lives, nothing will ever feel quite the same again; her absence is everywhere

Basmah said:

We are extremely grateful to the Coroner and jurors for their humane and comprehensive handling of the complex evidence in this case. Nothing can bring Melissa back, and it is only right that the ligature team’s failure has been recognised and recorded in the Record of Inquest. By law, the jury’s conclusions are narrow – limited, as they must be, to factors which the jurors unanimously, or by a majority, found probably caused Melissa’s death. But Central and North West London NHS Trust, or CNWL – who manage the eating disorder service at Vincent Square – were present and represented in the Coroner’s court throughout this inquest. They heard the experience of Melissa’s family on arrival at VSEDS, who described the admission processes as distant, cold and incomplete. Melissa’s family continue to feel that their daughter’s distress wasn’t taken into consideration by those who they – and the law – had entrusted to keep Melissa safe. It may be the case that patients are often distressed by the fact of an involuntary admission. But that does not excuse an uncaring response to that distress. The expectation by Management that ligature assessments are routinely left to nurses was a surprising revelation in the course of this inquest. Putting aside care plans, environmental risk assessments, checklists and audits, what Melissa’s parents had hoped was that ward staff would engage their daughter on a human level, as the paramedics had successfully done. That just didn’t happen for Melissa, and we can only hope that her family’s grief is powerful enough to compel organisational and individual change within CNWL