April 25, 2024

Lillian Lucas: Inquest finds neglect contributed to death of NHS inpatient at Cygnet Hospital

Before HM Area Coroner Dr Peter Harrowing

Avon Coroner’s Court, Bristol

15 – 24th April 2024

Lily Lucas, 28, died after being found unresponsive whilst an NHS inpatient at a privately run Cygnet Hospital in September 2022. Now an inquest has found widespread failings in the care provided to Lily and concluded that her death was contributed to by neglect.

Lily’s family describe her as beautiful, loving, generous and hilarious. She had a history of mental ill health and a diagnosis of schizophrenia. She had hoped this hospital admission would be an opportunity to get better through engaging with therapeutic opportunities at the unit.

On 15 June 2022, Lily was admitted to Milton Ward at the Cygnet Hospital at Kewstoke, Weston-super-Mare under Section 3 of the Mental Health Act 1983, after an escalation in her mental health symptoms. She initially made good progress, but her mental health again deteriorated around August 2022.

On 5 September 2022, Lily was prescribed Clozapine to help manage her symptoms. This is a drug that Lily was scared about taking, as she was aware of the severe side effects some people suffered. Her family raised her concerns with the treating team.

In the hours leading up to her collapse, Lily was noted by numerous staff on the ward to be drinking excessive volumes of fluid and eating large quantities of food. She was also seen vomiting profusely and acting in a disinhibited and disorientated way.

This was uncharacteristic behaviour for Lily and ought to have been recognised as a concerning deterioration in both her physical and mental health.

Tragically, in the evening of 8 September 2022, Lily was found unresponsive in her room and after CPR was transferred to the Bristol Royal Infirmary for treatment. She subsequently died on 9 September 2022.

Now an inquest jury concluded that there were gross failings in her care amounting to neglect. They found that:

  • Lily died from cardiac arrest due to complications of psychogenic polydipsia, resulting from her schizophrenia.
  • Throughout the afternoon of 8th September, there was a failure to adequately monitor Lily’s worsening mental and physical condition.
  • Neither urgent nor adequate medical attention was provided nor sought, in line with Cygnet policies.
  • There was inadequate response and concern for Lily’s ongoing presentation.
  • Opportunities were missed to render care which would have prevented Lily’s death.

During the inquest, the jury heard evidence about how the ward had unsafe staff levels on shift for that day. Despite there needing to be a minimum of two registered nurses and six support workers on shift on the ward, there only was one registered nurse and five support workers, all of whom were agency or bank staff.

This was further compounded by the requirements of other patients on the ward. Four of the support workers were engaged with enhanced observations for other patients with high needs which meant there was only one support worker available to support the ward generally.

In her evidence the Nurse in Charge (the sole qualified member of staff on duty that shift) explained she was unable to fulfil her role properly due to unsafe staffing levels. She conceded that this meant that opportunities to save Lily’s life were missed.

Lily’s family said:

We are grateful to the jury for their careful consideration of the inquest over the 8 days. Their conclusion confirms our worst fears about the care that was provided to Lily during her time at Cygnet Hospital.

Whilst we are glad that their conclusion recognises the significant and various failings in care provided to Lily it is nonetheless utterly heartbreaking to know that her death was entirely avoidable. We were alarmed by the lack of contrition from many of the Cygnet workers who gave evidence during the hearing, including some who failed to accept the clear inadequacies in their response to Lily’s condition even now, 18 months after Lily’s death. 

We miss her every day and always will.”

Ali Cloak of RWK Goodman, said:

“During her admission to Cygnet Hospital, Lily was highly vulnerable and this was well known to those caring for her. Lily and her family trusted Cygnet to support her recovery and to keep her safe.

Despite the marked deterioration in her physical and mental health from the morning of 8th, she did not receive the basic care she needed which would have altered the course of events.

Her concerning presentation, particularly the excessive drinking of fluids, was not treated as a medical emergency as it ought to have been according to Cygnet’s own policy. The emergency services were only called in the evening after she had been unresponsive for some time. The inquest confirmed that Lily’s death was entirely avoidable.

We welcome the changes which have been implemented at Cygnet but these come much too late for Lily and her family. We sincerely hope lessons are learned by all involved so that history doesn’t repeat itself.”

Selen Cavcav, Senior Caseworker at INQUEST who supported the family said:

“No family should be left to endure the horrors of losing their loved one in a place where they ought to have been safe and cared for.

Grossly inadequate failures in this case to provide the most basic mental health care is sadly not unique to this case but part of a systemic pattern of failures.

This is another shocking example of unaccountable private companies like Cygnet putting profit before patient safety. We can no longer tolerate the use of public money to fund private provision which is failing to keep people safe.”



For more information please contact Leila Hagmann on [email protected].

The family are represented by INQUEST Lawyers Group members Ali Cloak and Miryam Vermaat of RWK Goodman and Marcus Coates-Walker of 1 Crown Office Row. They are supported by INQUEST senior caseworker, Selen Cavcav.

Other Interested persons represented are Cygnet Group and Nonhlanhla Sibanda, Mental Health Nurse.Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.

Other relevant cases

  • Peter Dickens, a 31 year old autistic man, died from choking at a residential care home run by Cygne, in 2021. Peter had a severe learning disabilitiy, a choking disorder and epilepsy. An inquest found that neglect contributed to his death. Media release.
  • Emma Pring, 29, died by ligature whilst an inpatient at Cygnet Hospital Maidstone in 2021. An inquest found that failures contributed to her death. Media release.
  • Dominic Vickars, 25, died a self-inflicted death at Cygnet Hospital Kewstoke in 2019. Dominic had schizophrenia. An inquest found that risk assessments were ineffective and a lack of clarity among staff about roles and responsibilities. Media coverage.
  • Claire Greaves, 25, died a self-inflicted death whilst an inpatient at Cygnet Hospital Coventry in 2018. An inquest found a failure to properly observe Claire and that staffing levels probably caused or contributed to her death. Media coverage.

In September 2023, Cygnet Health Care was finded £1.53 million after pleading guilty in a criminal prosecution brought by the Care Quality Commission over an inpatient’s self-inflicted death in London.

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