Open verdict recorded over death of 22-year-old in mental health unit due to 'insufficient evidence'

Credit: Family handout. Image of Lauren Ellis
Lauren Ellisa (pictured) died on 12 October 2017. Credit: Family of Lauren Ellis

The family of 22-year-old Lauren Ellis, who died at a mental health centre in Guernsey in 2017, say they are relieved the process is finally over.

It comes after an open verdict was returned at an inquest into her death.

The Inquest Court found insufficient evidence to decide how death occurred on Thursday 28 March.

Lauren was voluntarily admitted to Oberlands Centre on 11 October 2017 following a series of self-harming incidents, but she died by the early hours of 12 October.

After the inquest, Lauren's mother, Dawn said: "Today's verdict I think was the right one for us you know. I didn't want it to be suicide because it wasn't suicide.

"She was not cared for. She went in there to be safe and looked after and it wasn't." Dawn added: "It's good that the legal side has come to a close, but going forward nothing has really changed for us, it just carries on as normal. She's still not here."

Delivering the verdict, Judge Graeme McKerrell said it was hard to understand why the process had taken so long.

He also said while he was unable to reach any conclusion, this did not suggest or infer blame on anyone.

A criminal investigation and an internal investigation undertaken by Health and Social Care into her death found two on duty nurses failed to carry out the necessary checks on Lauren every 15 minutes.

The investigation also found official records of the checks that should have been carried out, had been falsified.

The former mental health nurses were charged with manslaughter but, in September 2019, the Royal Court found them not guilty.

If you have been affected by issues in this article and need help, support is available:

  • CALM, the Campaign Against Living Miserably, runs a free and confidential helpline and webchat. It also supports those bereaved by suicide, through the Support After Suicide Partnership (SASP). Call 0800 585858 (daily, 5pm to midnight).

  • Mind is a mental health charity which promotes the views and needs of people with mental health issues. It provides advice and support to empower anyone experiencing a mental health problem, and campaigns to improve services, raise awareness and promote understanding. Call 0300 123 3393 or email

  • Samaritans is an organisation offering confidential support for people experiencing feelings of distress or despair. Phone 116 123 (a free 24 hour helpline) or email

  • YoungMinds is a resource with information on child and adolescent mental health, but also offers services for parents and professionals. It is the UK’s leading charity fighting for children and young people's mental health, and wants to make sure all young people can get the mental health support they need when they need it. Visit

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