Dova Unit in Barrow criticised after failings highlighted during inquests into patient deaths

Recent inquests into the death of Lauren Braithwaite, 27, who took her own life in March 2020 and Emma Beth Goulding, 24, who died in April 2020 after attempting to hang herself.

Both were treated for mental health issues by the Dova Unit based at Dane Garth at Furness General Hospital, and both were deemed to have been failed by the mental health unit.

Both families raised their concerns about their care during the inquests, and Miss Goulding’s father, James, had expressed his belief that ‘neglect’ brought about his daughter’s death. Coroner Ms Kirsty Gomersal concluded this was not the case but stressed that neglect had a very specific meaning in a coroner’s court and was a rare finding for a coroner to make.

Communication, documentation, treatment and care, and staffing levels are all factors that were highlighted by the coroner and were areas of concern, however a report to prevent future death was not submitted in either case because the coroner was satisfied work had been done by the Lancashire and South Cumbria NHS Foundation Trust to help stop similar tragedies occurring in future.

A spokeswoman for Lancashire & South Cumbria NHS Foundation Trust said: “We reiterate our sincere condolences to any family who have lost a loved one whilst receiving care from Lancashire & South Cumbria NHS Foundation Trust.

“The Trust took over the running of South Cumbria Mental Health and Learning Disabilities Services (of which the Dane Garth site and Dova Unit is a part) in October 2019 and, since that time, we have worked hard with our staff to improve patient safety and experience.

“Her Majesty’s Coroner has recently heard evidence of the service improvements in relation to increased staffing, training and policies and protocols. We have also placed a great deal of emphasis on improving communication with families, acknowledging that it can be a very frightening experience, for not just the patient, when someone is away from home and their usual support network.

“The Coroner was satisfied that the Trust has taken the incidents in March 2020 very seriously and have worked to mitigate against the possibility of these reoccurring”.

Kitty Birtwistle, the daughter of Daniel Birtwistle from Ulverston, who took his life when on day release from the unit said she was upset reading the inquest reports from these two young women as it appeared the trust had ‘learned nothing’ from the death of her father did not really listen to what we had to say and did not take on board his personality and understand his personality.

“They actually admitted that they did not look after him properly and had to put new measures in place following his death.

“They made my relationship with my dad really tough as I went against his wishes of leaving the unit in front of him and I am not sure if he forgave me for that before he died.

“Seeing these reports really upsets me because it is clear they have not learned anything as the same mistakes are being made.”

Miss Birtwistle has since trained as a suicide first aider and works with Suicide Bereavement Support Group for Cumbria to help others.

South Lakes MP Tim Farron, speaking during mental health awareness month, believes that mental health is awareness is more important than ever.

“The public need to be ensured that those who scrutinise the failings at the trust are independent and are not connected to the trust and give them an easy rise because we won’t learn from mistakes without proper scrutiny.

“My sense is that we are going to see an increase coming out of lockdown, eating disorders for example have doubled.

“The relative certainty of lockdown going into a world of uncertainty is where the real backlog of mental health need is going to rocket. So, we have to take this as seriously as physical health.

“Yes, it is important to have a volume and quality of care available for people in south Cumbria, it is vital.”

Tim Farron

A report following an inspection conducted by the Care Quality Commission in 2014 stated the trust need to make improvements in relation to records.

A spokeswoman from Morecambe Bay Clinical Commissioning Group said: “We would like to offer our sincere condolences to the families involved during these difficult times.

“In October 2019 mental health services within Morecambe Bay were transferred to Lancashire and South Cumbria NHS Foundation Trust and since then a significant programme of improvement has been delivered.

“We would like to reassure the population of Morecambe Bay that all actions towards delivering a safe and effective service at the Dova Unit in Furness General Hospital are being met and that patient safety in the right environment remains at the forefront of any changes that have been implemented.”