My daughter lay dying as NHS nurses thought she was just asleep

The heartbroken family of a young woman left dying on the floor for an hour by nurses who thought she was sleeping say she was 'let down' by an NHS trust.

Shannara Donnelly, known as Jade, was considered at risk of self-harm and was supposed to be watched 'at all times' whilst she was at Chase Farm Hospital in Enfield, north London.

However, medical staff wrongly observed the 22-year-old by watching CCTV cameras and missed her collapsing to the floor in her room at the unit.

Jade's jury inquest heard nurses saw her on the ground but presumed she was sleeping and left her unresponsive for more than an hour.

Though jurors were unable to rule whether Jade had committed suicide, they concluded that failures by Barnet, Enfield and Haringey Mental Health NHS Trust had contributed to her death.

Her mother described Jade as 'special, kind and considerate young woman who 'suffered greatly in her life but still cared tremendously for others'.

The director of the Trust apologised to Jade's family during his evidence to the inquest and admitted 'shortcomings' in her care. 

Her condition meant she required 'one-to-one' care and continuous observation '24/7, seven days a week'.

In a statement released following the inquest's conclusion, her bereaved family said she had been 'let down' by a system that 'should have kept her safe'.

Her mother Kerry Donnelly said: 'As a family we have been desperate to know what happened to our beloved Jade in her final hours.

'She was taken by police to a place of safety at Chase Farm Hospital in June 2023.

'Although she was under strict observations, she never made it home alive.

'Her grandmother and I have struggled deeply with this fact, particularly as we didn't know she had entered the facility until we got the call that changed our lives forever.

'We have, and will remain, determined to understand how she was let down by a system which should have kept her safe during her darkest hours.

'[Jade] believed, as we all would, that her admission to a place of safety would be the beginning of a journey where she could get the help she needed.

'Tragically, whilst in the care of Chase Farm, a very beautiful leaf fell from our family tree.

'She suffered greatly in her life but still cared tremendously for others, sometimes to her own detriment.

'She was a special, kind and considerate young woman who will forever remain in our hearts and I believe we owe it to Jade to continue fighting until we understand why we now have to face life without her, a sentence no mother should have to face.'

The inquest, held at George Meehan House in Wood Green, north London, heard Jade struggled with her mental health and was at risk of self-harm.

Just days before her readmission to Chase Farm she had been arrested after threatening to harm herself and telling police she 'wanted to die', jurors were told.

Area Coroner Tony Murphy read admissions from the Barnet, Enfield and Haringey Mental Health NHS Trust, including that Jade 'shouldn't have been sent' to Chase Farm Hospital due to an earlier incident at the 'secure' unit, that her risk assessment was inadequate and that she 'should have been within eyesight observations'.

The Trust further admitted that necessary safety checks were not carried out by nursing staff at the facility - which was also housing another patient at the time.

The Trust also admitted that CCTV observations by staff were an inadequate form of observation.

The inquest heard Jade had died 'apparently [by] her own hands'.

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Returning a narrative verdict, jurors said the item Jade had used to strangle herself was also 'not captured' in the Trust's ligature risk policy.

Jade's family say they were shocked to be told she had died 'apparently [by] her own hands', saying their interactions with her on the day of her death '[didn't] seem to fit' with someone who wanted to take their own life.

Prior to her death, a doctor had refused to discharge Jade from the unit, which had greatly angered her.

Ms Donnelly explained that her daughter had been diagnosed with ADHD and that she'd home-schooled her for a time, having been bullied at school.

The inquest heard Jade was an active member of both the Army and Police cadets, as well as being a member of the Royal British Legion.

Ms Donnelly explained that Jade had struggled during lockdown and had recently lost three close members of her family before her death.

CCTV footage played to jurors from the day of Jade's death showed members of staff observing the girl on cameras and through 'peephole' windows, but not completing observations required under her level of care.

Jurors also concluded that the Place of Safety Suite (POSS) at Chase Farm was 'inadequately staffed' on the night of Jade's death.

Mark Pritchard, Managing Director at Barnet, Enfield and Haringey Mental Health NHS Trust, began his evidence by apologising to Jade’s family.

“I want to offer my sincere condolences, on behalf of the Trust, for the shortcomings in Jade’s death,” he said.

Mr Murphy took the court through the Trust’s policy guidelines for patients under Level Three care, which Jade was under, which states they should be within sight ‘at all times’.

Guidelines also stated that though CCTV observation could be used to support staff, 'it should not be used in place of observations and engagement'.

They also stated patients should be observed 'attentively'.

Mr Murphy asked Mr Pritchard: 'Does it appear to you that, during the footage you saw, that Jade's observation was conducted by staff attentively?'

'No, I don't believe it was,' the latter replied.

Emma Wray, a clinical negligence lawyer at law firm Hodge, Jones & Allen, who represented Jade's family at her inquest, warned that the NHS risked 'failing the future' of young people like Jade unless they get the care they need.

She said: 'This inquest was a painful but crucial step for Jade's family, who had to sit through each harrowing detail of the last moments of her life and to witness the failures which led to her untimely death whilst detained in a place of safety and supposedly under consistent observation.

'We are grateful to the Coroner, court staff and the jury for their compassion and understanding and hope that lessons have been learnt.

'We are dealing with a growing number of these cases and repeatedly witnessing the impact it has on families across the country.

'As warned by the Care Quality Commission (in their annual assessment of the state of health and social care in England published 25/10) we are at risk of 'failing the future' of our children and young people, just like Jade, if we can't provide the care they need today.'