Lauren Ellis died on the Crevichon Ward at the Oberlands Centre on the 12 October 2017.
She had Emotionally Unstable Personality Disorder. A condition which caused her to harm herself and on occasions attempt suicide.
Former mental health nurses Rory McDermott, 32, and 31-year-old Naomi Prestidge deny manslaughter by gross negligence. They were the nurses on duty the night Lauren Ellis died on the ward.
On the evening of the 10 October 2017, Lauren attended A&E saying she had thoughts of self-harming. She was discharged but returned after midnight on the 11 October. She had cut her arm. The wound was bandaged and Lauren was discharged. She came back to A&E a third time. This time, the self-harm was more severe and she was offered respite at the mental health unit.
Lauren agreed and was admitted to the Crevichon Ward on a voluntary crisis admission.
She was put on level 2 observation checks, which meant she was to be checked every 15 minutes by a staff member.
At 8pm, mental health nurses Naomi Prestidge and Rory McDermott and two healthcare assistants started their shift.
Following a phone call late that night with Lauren, her mother, Dawn Ellis called the ward to raise concern for her daughter's mental state. She spoke to Rory McDermott.
Just before midnight Rory McDermott phoned the on-call psychiatrist, Dr Bhintade, to prescribe medication for Lauren to help her settle.
Naomi Prestidge phoned again at around 12:45am and text Rory McDermott to tell him what had been prescribed. He replied, ‘she needs a line of ket’.
Lauren was last checked at 1am.
Rory McDermott and Naomi Prestidge failed to carry out 6 observation checks in a row on Lauren and the other patients staying on that part of the ward.
CCTV evidence shows during that time the ward was not busy and for the most part they were sat in the nurses station. They were at times on their phones, looking up holidays.
Rory McDermott falsified records claiming observation checks on Lauren were being carried out. He left the nurses station at around 2:20am to see a colleague on a different part of the ward.
Lauren was found at 2:42am on the floor of her room by Naomi Prestidge. She had strangled herself with the bandage A&E staff had used to dress the wound on her arm the night before.
In the minutes that followed her discovery Naomi Prestidge falsified records - logging observation checks which never took place.
Naomi Prestidge was the shift coordinator. She said in a statement she thought Mr McDermott had carried out the checks. She said a breakdown in communication was the reason for the checks being overlooked.
A time of death for Lauren cannot be determined. Defence teams argue that, according to pathologist evidence, it is possible that Lauren could have applied the ligature and died within 15 minutes. They argue therefore that Lauren could have died before the first check was missed at 1:15am.
Advocate Clare Tee, representing Naomi Prestidge argued doctors did not assess Lauren’s risk accurately and that they should have put her on one-to-one observations.
She said in the handover Ms Prestidge received, she was not told about the bandage on Lauren’s arm or her admissions to A&E the night before. She said there is no record Lauren had a bandage on her. Advocate Mark Dunster, representing Rory McDermott, said Mr McDermott also did not know about the bandage on Lauren’s arm.
Advocate Clare Tee said there was a catalogue of errors, systemic failures and missed opportunities leading to Lauren’s death.
She argued that the admitting doctor, Dr Rahul Bhintade, did not carry out a one-to-one assessment of Lauren on the ward, as he says he did, but did it remotely from his office. Dr Bhintade has given evidence and said he did carry out this assessment with Lauren on the ward. She also said Dr Bhintade missed an opportunity to reassess Lauren when he was phoned by the nurses to prescribe medication for her.
Speaking about Ms Prestidge, she said: "It was clear that the breach of duty was the last in a long line of failures in Lauren’s care."