Inquest jury finds multiple failings contributed to the death of Zoe Watts

The lawyer for the family of 19-year-old woman, who died whilst in the care of Oxford Health services, says that healthcare for adolescents and young adults needs to be improved following the findings of a jury that multiple failings contributed to the death of Zoe Watts in March 2017 on the Ruby Ward at the Whiteleaf Centre in Aylesbury.

The jury inquest, which concluded on the 13th July 2018, found that “risk-related incidents were inconsistently recorded and communicated”, “historical risks were not given sufficient weight”, and “communication [with Zoe and her family] was neither timely, formal, nor sensitive”.

Zoe from High Wycombe in Buckinghamshire was a former gymnast who had transitioned to the GB trampolining squad. She first became ill with obsessive compulsive disorder in late 2012, this later developed into a more complex mental health illness.

Zoe was referred to child and adolescent mental health services (CAMHS), and then placed at the Priory in Richmond, southwest London where she spent around seven months, before improving enough to return to school. 

However, after becoming ill again in 2014 she was placed in the Highfield Unit, an adolescent inpatient facility in Oxford. Zoe was transferred to the Ruby Ward, after she had turned 18 and no longer in the care of CAMHS. 

This transition from an adolescent unit to an adult ward, was a backward step according to her father Keith, who told Buzzfeed news.

“The Ruby Ward is a unit where they put all kinds of illnesses in one place,”

“You could be bipolar, you could be schizophrenic, you could be a drug addict, you could be an alcoholic — you could be anything across the spectrum of mental health, all in one place.”

Her mother, Paula Watts, told Buzzfeed: “CAMHS rely on the family.

“But then when they go to adult mental health they’re told that they have to take responsibility. But all through the CAMHS time, you’re told as parents that you’re to do everything for them, and then suddenly the child, who is now an adult, has to take that responsibility. It’s overnight as well.”

A number of relapses were interspersed with positive momentum toward a more settled routine for Zoe, including studying for a nursing qualification, however, by early 2017 Zoe had stopped taking her medication and her and her family struggled immensely with a rapid decline in her health.  February 2017 was, as Mr Watts told the Inquest, “a really difficult month”; Zoe took multiple overdoses and refused treatment, leading to her requiring restraint and sedation to save her life. Zoe was finally sectioned on 19 February 2017 and placed on the Ruby Ward.

She was discharged again on 3 March 2017, but her condition quickly deteriorated, and Zoe took another serious overdose. During this time Zoe’s parents repeatedly contacted Zoe’s healthcare professionals and pleaded for a plan for Zoe to try to manage her escalating risk and the immense strain on the family.

Zoe was readmitted to Ruby Ward on 16 March 2017. Four days later staff wanted to discharge her again. Zoe voiced her concerns, saying she did not feel safe and feeling as though the staff had given up on her. 

She died the day before she was due to be discharged.

The jury found that failings in relation to how Zoe’s intended discharge was planned possibly contributed to her death. They concluded that more flexibility in the discharge date may have helped to alleviate Zoe’s feelings of abandonment in the days leading up to her death.

They also found that risk-related incidents were inconsistently recorded and communicated, with historical risks not given sufficient weight.

They also found that there were failings in the communication with Zoe and her family, stating that communication was neither “timely, formal, nor sensitive.”

Merry Varney from the human rights team at Leigh day, who represented the Watts family, said: 

“The Inquest process has allowed Zoe’s family to have a better understanding of the circumstances of Zoe’s death and the jury’s finding of multiple failings which may have contributed to Zoe’s death are a vindication of the concerns they, and Zoe, expressed before she died.

“It is imperative that the welcome steps the Trust are implementing to improve care are audited and reviewed regularly to prevent more potentially avoidable deaths. 

“I also hope additional steps are taken to improve communication with patients and families; it is entirely unsatisfactory for a family to learn at an Inquest that their emails to Zoe’s Community Consultant Psychiatrist were not going to be responded to – a simple automated message could redirect such correspondence.

“Senior Coroner Butler noted repeatedly that the bereaved family should be at the heart of the Inquest process - something which should be, but sadly isn’t, replicated across the country.”

Keith and Paula Watts jointly issued this statement following the conclusion into their daughter’s death:

“This inquest has revealed substantial evidence that our beautiful daughter Zoe’s life was cut short not only by her illness but also by the failings of a system which should have helped her recovery and protect her from the fatal effects of initially Anorexia Nervosa.

“The outcome of this inquest was never going to be without emotion, firstly we are now aware that her death could have been prevented but also this could have so easily been covered up.

“This traumatic experience on our family has been devastating, however I would like to thank the support and guidance of our legal team and we can now start to rebuild our lives.”

Samaritans can be contacted on 116 123.