New inquest ordered for vulnerable woman who ‘effectively starved to death’ in psychiatric care

The family of a woman who “effectively starved to death” while in psychiatric care have won a High Court fight for a new inquest into her death.

Jennifer Lewis, 45, died from malnutrition on July 27 2017 after being detained at the Bracton Centre (pictured) in Dartford, Kent, a secure unit run by Oxleas NHS Foundation Trust.

Ms Lewis, who suffered from paranoid schizophrenia, had been detained under the Mental Health Act since 2010, around which time she underwent bariatric surgery to lose weight.

An inquest into her death heard Ms Lewis’s weight remained stable until around 2016, when staff at the centre became concerned about her “significant” weight loss, which had caused hair loss and affected her eyesight.

Ms Lewis was twice admitted to hospital in early 2017 over concerns about malnutrition, but her physical decline continued.

She was found semi-conscious in her room on July 14 2017 and taken to Darent Valley Hospital where, despite treatment, she died nearly two weeks later.

Last April, a jury at North Kent Coroner’s Court concluded Ms Lewis died from malnutrition “due to inadequate provision and intake of sufficient nourishment and nutrition, furthered by an inability to (arrange) the necessary medical intervention whilst at the Bracton Centre”.

But Ms Lewis’s family argued the senior coroner for North West Kent, Roger Hatch, had wrongly failed to leave a conclusion of neglect by the trust to the jury.

On Wednesday, their barrister Julian Waters told the court Ms Lewis had “over a period of about one year effectively starved to death through want of sufficient nutrition”.

He submitted: “During that period, staff at Bracton knew that the deceased was suffering from malnutrition.”

Mr Waters said the trust did not follow its policies in relation to the management of nutrition and hydration.

He said there was “scant evidence” staff monitored Ms Lewis’s nutritional intake, and pointed out that a doctor admitted at the inquest her weight records were simply “copy and pasted”.

Mr Waters added the coroner issued a prevention of future deaths report following the inquest, which recorded his concern about the trust’s “failure to provide suitable or adequate care for her needs”.

He argued the coroner’s “irrational” decision to prevent the jury from reaching a conclusion of neglect was “wholly inconsistent with his concerns” expressed in that report.

Lord Justice Davis – sitting with Mr Justice Edis and Judge Mark Lucraft QC, the chief coroner of England and Wales – ruled a finding of neglect was “properly open to the jury on the evidence” and directed that a fresh inquest should take place.

He said the background to the case was “somewhat disconcerting”, adding: “Here we have an individual detained under the authority of the state, pursuant to the mental health legislation, in a state-controlled institution who has died of malnutrition.”

The judge stated that Ms Lewis had “suffered pronounced weight loss in the months before she died”, with “accompanying manifestations of physical decline and malnutrition”.

Despite that, he said, “the medical records were never properly maintained or updated and, on the face of it, the written policy on hydration and nutrition simply was not adhered to”.

Lord Justice Davis concluded: “This withdrawal of such an issue of neglect from the jury was not one which was reasonably open to the coroner and it has, in consequence, resulted in a flawed inquest.”

Ordering a new inquest, the judge added that “it would be better if such an inquest were conducted before a different coroner”.

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