An Inquest has heard that Nadia Shah, 16, died on 15 January 2019 whilst being detained for her own safety under the Mental Health Act at a secure mental health unit, Elysium Healthcare’s Potters Bar Clinic, Hertfordshire.  Elysium Healthcare is a private provider commissioned to provide mental health care to NHS patients.

Following a 2 week Article 2 inquest, the jury returned a conclusion that Ms Shah’s death was due to misadventure contributed to by inadequate care provided at the Potters Bar Clinic.  The inquest jury found multiple failures in Ms. Shah’s care, including “an unsatisfactory implementation of the care plan”, “a failure to sufficiently engage and provide cohesive care” and “a failure to adequately report observations to properly inform assessment of risk”.  They also criticised the lack of clarity around the timing of observations.  According to the evidence of the consultant psychiatrist responsible for her care, Ms Shah should have been checked at least every 15 minutes, but she was found after 19 minutes with difficulty breathing due to a ligature that she had placed around her neck, probably no more than 3 -4 minutes before she was found.

Once Ms Shah was found, the response of the staff was chaotic.  The jury heard evidence from two experts in Intensive Care Medicine that CPR should have been commenced within two minutes of Ms Shah being found, and this should have included chest compressions, rescue breaths and bag valve mask ventilation.  The jury concluded that the emergency and resuscitation response was lacking and CPR was not carried out promptly by the clinic staff, and these failures contributed to Ms Shah’s death.

Sarah represented the family at the inquest and was instructed by Catherine Knight at Irwin Mitchell Solicitors, you can read their press release here.

The case has been widely reported today by The BBC ,The Mirror and local press.


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