Five women die at mental health hospital and the questions remain

This newspaper has seen damning documents raising serious questions about Mill View Hospital, Hove, and the reaction to Janet’s death from trust bosses after she walked out of the Caburn Ward twice in a matter of hours before she was killed in March last year.

We can exclusively reveal that a coroner previously stepped in to call for more safety measures after a woman died while in its care in 2013.

Janet Muller was found dead after being burned alive in the boot of a car in Crawley. Christopher Jeffrey-Shaw was sentenced to 17 years in prison last week for her manslaughter.

The Argus can today expose internal e-mails between those at the mental health hospital in Nevill Avenue days after Janet’s death that highlight concerns about the circumstances.

She is described by Karen Braysher, governor for Brighton and Hove NHS Sussex Partnership Foundation Trust, as “falling prey to murder” when she “should have been protected” whilst in care. She also made reference to night-time male visitors.

The governor said in an email to Colm Donaghy: “The poor women [sic] should have been protected from male night-time callers.”

When asked about those concerns Mr Donaghy, the trust’s chief executive officer, told The Argus he could not speak on “the actual specifics of that because I don’t have the details to hand”.

He added: “But it’s a hospital where people are able to have guests and visitors and we encourage that when it helps someone’s recovery.

“It’s managed in a way that the unit is safe and that would have been done in that situation.”

The Argus can reveal that following the 21-year-old’s death, Mr Donaghy said the findings of a thorough report would be shared widely.

However, the report’s findings are being kept secret despite The Argus requesting their release.

One of the five deaths, that of Danuta Corbett, resulted in the coroner telling the trust to take steps to prevent further deaths.

Mrs Corbett jumped to her death in November 2013, from the eighth floor flat window of her home while on escorted leave.

Her inquest revealed how the escort hadn’t been told Mrs Corbett had threatened to kill herself by jumping from the flat.

In February, 2012, Brighton teacher Jessica Philpott, 38, hanged herself in the garden of Caburn Ward – three months after Mill View had been told by the CQC to improve patient safety.

Her inquest heard that on the day of her death she had made two attempts at self-harm.

Lessons had still not been learned, because in March last year, Janet Muller was killed.

The Argus asked why the investigation into how she walked out of the hospital was not made public, but Michael Mergler, deputy managing director of Sussex Partnership Trust, which runs the hospital, dismissed the idea.

He said: “We shared it with our commissioners, we shared it with the local authority and we shared it deeply with the family.

“One of the reasons we don’t share it further is that it has sensitive information about individuals, staff and other patients.

“However, we’re very open with yourselves about the lessons and measures we’ve put in place. That learning has been shared, but not the details of the report.”

The changes as a result of the Janet Muller investigation included restricted garden access, a climb-proof fence and more training for staff.

• Also read: The Argus comment - Keep review open

INQUIRY FOLLOWING JANET’S MURDER LED TO CHANGES ON TROUBLED WARD

JANET Muller is the latest vulnerable person to die while under the care of the same mental health hospital ward.

Back in 2010, four patients under the watch of Mill View mental health hospital committed suicide between March and October and a review was carried out before recommendations were made to improve patient safety.

But since then there have been more cases involving patients of Caburn Ward, an acute ward for women, which have raised concerns for hospital governors.

Documents show how Danuta Corbett jumped to her death in November 2013 from the eighth floor flat window of her home while on escorted leave.

A coroner’s report reveals how the escort had not been told that Mrs Corbett had threatened to kill herself by jumping from the flat.

In February 2012 religious education teacher Jessica Philpott, 38, hanged herself in the garden of Caburn Ward three months after Mill View had been told by the Care Quality Commission to take steps to improve patient safety.

Her inquest heard that despite two attempts at self-harm on the same day, Miss Philpott was able to kill herself and was found hanged in the Mill View garden.

In April 2012 Jackie Stansby, 53, committed suicide after reportedly being discharged on the approval of a doctor who had not looked at earlier reports which had repeatedly argued for continued detention.

Her inquest found the decision to lift her detention was lawful but Ms Stansby’s daughter later criticised Mill View.

The trust stated another Caburn Ward patient, Philippa Mortiz-Parsons, has also died since 2011. A sixth patient, who has not been named, died of natural causes.

A spokeswoman said: “Six patients who were under the care of Caburn Ward have died since 2011. There have been no deaths involving patients of Caburn Ward since this tragic incident (Janet Muller’s death).”

Janet Muller, 21, was found dead in the boot of a burned out car in Ifield, last March.

And last week Christopher Jeffrey-Shaw, 28, was sentenced to 17 years in prison after being found guilty of her manslaughter.

Miss Muller, a German national studying at the University of Brighton in Eastbourne, was placed into the care of Mill View on March 3 after experiencing mental health problems.

On that same day the hospital recieved planning permission to raise a fence in the women’s garden because they knew that it was a problem.

On March 12, she absconded by walking out of the front door of the hospital, which is run by Sussex Partnership NHS Foundation Trust, at about 7.45am.

She was later found in the Devil’s Dyke area of Brighton and returned by officers from Sussex Police at 11.30am.

But sometime between 10pm and 10.15pm that evening she escaped again by climbing over a 2.3m wall in the garden.

Internal hospital trust emails seen by The Argus expose how Miss Muller is one of six patients of Mill View Hospital’s Caburn Ward to have died between 2011 and 2015.

A few days after her death, one of the trust’s governors, Karen Braysher, wrote furious emails to the chief executive, Colm Donaghy, demanding answers and saying Miss Muller “should have been protected”.

In the emails, obtained under the Freedom of Information Act, Braysher said Miss Muller had “fallen prey to murder whilst in our care”, adding: “Please explain.”

After receiving no response, Ms Braysher then posed a number of questions about CCTV, security patrols and perimeter safety.

She wrote: “We are too late as she has been murdered as a result of being allowed out or escaping. I am sadly upset that one of my constituents has met her demise whilst in our care. Horrific.”

In the same email, Ms Braysher wrote: “I am devastated that yet another life has been lost from Caburn Ward at Mill View.”

The full details of an internal trust investigation into Miss Muller’s case are being kept secret despite the chief executive, Mr Donaghy, telling Karen Braysher in an email on March 20 last year that “(we) will share the findings widely”.

A spokeswoman said it was recommended that some staff undergo further clinical training and added: “Changes have also been made to improve the process for carrying out risk assessments for individual patients since this tragic incident.

“All staff have been involved in the investigation into the circumstances surrounding Miss Muller’s care and have undergone further training as a result of this terrible incident. Nobody has been disciplined.”

She added: “We would like to express our sincere condolences to the family of Ms Muller following her tragic death.

“We would also like to apologise unreservedly for the fact that Ms Muller absconded from hospital whilst she was under our care.

“The circumstances leading to Ms Muller’s death could not have been anticipated. This was a tragic case. Ms Muller was under our care and should not have been able to abscond from the hospital.”

Asked about the other deaths relating to patients of Caburn Ward, she added: “Every death is a tragedy and we take any death extremely seriously. When a death or serious incident takes place we do everything we can to establish whether there is anything our services can learn from it and do differently in future.”

SOME ANSWERS BUT QUESTIONS REMAIN

Colm Donaghy

A HOSPITAL boss previously said the results of an investigation into failings that led to the escape and death of Janet Muller would be shared widely, but is now stating they must remain internally.

Colm Donaghy, chief executive of Sussex Partnership NHS Foundation Trust, emailed Karen Braysher, governor for Brighton and Hove NHS Sussex Partnership Foundation Trust, after the 21-year-old’s death.

He wrote: “I can assure you that we are completing a thorough and comprehensive investigation and will share the findings widely.”

But when The Argus pressed Michael Mergler, deputy managing director of Sussex Partnership Trust, which runs Mill View hospital in Nevill Avenue, Hove, he refused to make the review public. He answered some questions but big ones remain.

Nobody was reprimanded after Janet walked out twice in a matter of hours on March 12, the second time to her death.

Instead, the trust carried out an internal review, which resulted in staff getting extra training on communication, risk assessment and time management.

A reporter argued this review could be made public with sensitive information deleted, and Mr Mergler said: “That could be a possibility, but the essence of the way we do it is about how we work with all our staff and services to really get to the centre of what happened.

“That’s about trust and if we’re sharing them as a public document, it’s betraying that trust.

“We follow a template that the whole NHS is governed by, we’re no different, but it’s about how we share our learning.”

The hospital introduced a taller garden fence afterwards but The Argus can reveal an application for this was put in before her escape and death.

Planning permission was granted for the fence on March 3, the day Janet Muller was sectioned under the Mental Health Act after she had suffered an acute psychotic episode, meaning she had lost touch with reality.

People are sectioned when they are deemed by health professionals to be putting their or someone else’s safety at risk and are suffering from a mental disorder. They are admitted, detained and treated in hospital against their wishes.

A member of staff at Mill View hospital has called Janet’s tragic death completely preventable, citing the known security weaknesses in the psychiatric ward from which she escaped.

CORONER VOICED CONCERNS FOLLOWING FATAL PLUNGE

ONE year before Janet Muller walked away from Mill View and into the clutches of her killer, the hospital had been told to take action to prevent future deaths. 

In November 2013 Danuta Corbett jumped out of her eighth floor window while on leave from the psychiatric hospital escorted by an agency worker who had been told nothing of her threats to do so. 

In March 2014, following an inquest that heard how the decision to allow her request to go home had also not been properly recorded, coroner Veronica Hamilton-Deeley wrote to hospital bosses to tell them to make sure it did not happen again. 

She wrote: “During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. “

Sussex Partnership NHS Trust responded by saying the consultant psychiatrist had “learned a great deal” from the experience and now carefully reviewed notes taken during ward rounds. 

The trust added: “It is clear that the communication with the agency nurse who was accompanying Danuta should have been much better. 

“The nurse responsible acknowledges this and will always ensure proper handovers take place in the future.”

It seems unlikely, it said, “that any of the shortcomings highlighted by this very sad case would have prevented the tragic outcome”.

Of the six people cared for by Caburn Ward who the trust says have died since 2011, four were investigated by coroners.

In Mrs Corbett’s case a jury found that she had killed herself, while narrative or open conclusions were given in the other three deaths. 

Of the two that were not investigated by the coroner, it is believed that one was from natural causes, while Janet Muller’s death was the subject of a murder enquiry.

MILL VIEW HOSPITAL: FIVE TRAGIC STORIES, FIVE TRAGIC DEATHS

JANET MULLER

STUDENT Janet Muller was admitted to Mill View on March 3 suffering from an acute psychotic episode.

On March 12 she walked out via the front door, was found in the Devil’s Dyke area and brought back.

But later that night, at around 10pm, she climbed over the wall of the psychiatric institute and on to Nevill Avenue. 

Little is known about what she did next, with CCTV capturing her in Boundary Road, Portslade, between around 10.30pm and 12.30am. 

At 1.13am she was caught on CCTV in Kingsway, Hove, walking east towards Brighton, the last time she was seen alive. 

The next afternoon she was found dead inside the boot of a burned out car in Rusper Road, Crawley. 

She had died from smoke inhalation. 

Last Friday Christopher Jeffrey-Shaw, 28, of no fixed address but formerly of Lakeside, Beckenham, was sentenced to 17 years in prison after being found guilty of her manslaughter. 

He had been charged with murder, but jurors could not be sure that he knew she was alive when he set fire to the car with her in the boot. 

Jeffrey-Shaw claimed he had only met Janet at a house in Crawley.

JACKIE STANSBY

JACKIE Stansby was found dead on Brighton beach on April 27, 2012, the day after her detention at Mill View was lifted. 

The 53-year-old was suffering from delusions including one that a criminal gang was after her and that her daughter had been kidnapped and replaced with an imposter.

An internal review into the case by Mill View, seen by The Argus, revealed her doctor had not looked at earlier reports arguing for continued detention before she was allowed to leave. 

Her inquest in October 2012 found that the decision to lift the detention was lawful.

Ms Stansby’s daughter, Chloe Pynn, told The Argus at the time she felt her mother was robbed of the “right to life” and she had not been sufficiently involved in the hospital’s internal review. 

She added: “I’d seen her get better before, and I had hoped I’d see it again. I feel she was not protected at Mill View. 

“I still cannot believe she is dead.”

She added: “The consultant only saw her ‘brightened’ mood the day she died, which is well observed on the last days of those who take their own lives.”

JESSICA PHILPOTT

TEACHER Jessica Philpott hanged herself in the garden of Mill View hospital while a patient there in February 2012.

The 38-year-old had taught religious education at Oakmeeds Community College in Burgess Hill until mental illness forced her to leave.

She suffered from borderline personality disorder from the age of 13 and had been admitted to hospital six times in the six months before she died, due to self-harm.

On February 1 she was taken to Mill View after harming herself while in accident and emergency.

Her inquest heard she had become upset on February 13 after learning she was to be discharged the next day, and in the afternoon she had twice tried to barricade herself in rooms to strangle herself.

Consultant psychiatrist Dr Sabine Munzinger said Miss Philpott felt she could safely harm herself at the hospital because she believed she would be found, and she would be more likely to manage her own safety if she was discharged.

On February 13 staff were checking on her every 15 minutes. But between 10.45pm and 11pm she went to the garden, where she was found hanging.

The coroner who carried out her inquest made no criticisms of the Sussex Partnership NHS Foundation Trust.

DANUTA CORBETT

SEVERELY distressed following the death of her husband, Danuta Corbett jumped from her eighth-floor flat while on escorted leave from Mill View on November 4, 2013.

The widower was a voluntary patient at the psychiatric ward and asked to go to her home in King’s Road, Brighton, to collect some papers. The 59-year-old was allocated an escort who had never met her and never worked on the ward before.

An agency worker, the escort was not told that the flat was central to Mrs Corbett’s distress or that she had threatened to kill herself by jumping from it.

Jurors at her inquest in March 2014 found that the leave was not granted in line with the trust’s policy, and that Mrs Corbett was documented as high risk at the time and on 15-minute observations.

Brighton and Hove coroner Veronica Hamilton- Deeley noted that none of the decisions regarding Mrs Corbett’s leave on November 4 had been documented.

She said the Sussex Partnership NHS Foundation Trust needed to take action to prevent future deaths.

PHILIPPA MORTIZ-PARSONS

Philippa Mortiz-Parsons was another patient on Caburn Ward who has died since 2011.

Details about her case were not available as The Argus went to press last night.

It is believed she is among the cases governor Karen Braysher was referring to when she said “yet another life has been lost from Caburn”.

Asked what that comment was referring to, a spokeswoman for the trust said: “Six patients who were under the care of Caburn ward have died since 2011.

“There have been no deaths involving patients of Caburn ward since this tragic incident (Janet Muller).”

The spokeswoman confirmed that five of the six who died were Janet Muller, Danuta Corbett, Philippa Mortiz-Parsons, Jacqueline Stansby and Jessica Philpott.

She added she could not provide a sixth name because the case had not gone to inquest and was therefore not in the public domain.

One of the six deaths was from natural causes, she continued.