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A hospital's failures contributed to the death of a woman who was found on a mental health ward, a jury has decided.
Emma Pring, 29, was receiving trauma therapy at the Cygnet Hospital in Weavering, Maidstone, when she died as a result of asphyxiation on April 20 last year.
The former nursery nurse had a long and complex history of mental health problems - including emotionally unstable personality disorder (EUPD) and post-traumatic stress disorder - after she was the victim of two sexual assaults when she was 18 and 19.
On Friday the jury, made up of six women and four men, concluded there was a misjudgement of her risk by those caring for her and their failure to properly observe her contributed to her death.
The group of men and women concluded: "Despite Emma’s documented and well known incidents of serious self-harm and suicide attempts in the days leading to her death, she was not placed on 1:1 observations which could have prevented her death at the time.
"Due to insufficient level of observations and a misjudgement of Emma’s actual risk, she had the opportunity to take her life.
"It is clear from a schedule of the CCTV footage that there was a failure to adhere to the policy regarding observation within a 15 minute window."
Ms Pring's mother Caroline Sharp, and the rest of her family, have been left angered after the jury's "damning findings".
She said: “Words cannot do Emma justice: she was a ray of light through her own darkness to her family and friends, and other people’s problems would always come before her own.
"She was the most loyal person you could meet and treated everyone with respect and as equals. Her smile made you smile too, and her laugh was infectious.
"When Emma was transferred to Cygnet Maidstone on July 23, 2020, I thought that she would receive Rolls Royce care, the best money could offer.
"I hoped it would be a turning point in Emma’s life. Instead, Emma was utterly failed by Cygnet.
"The jury’s damning findings vindicate the concerns about Emma’s care that we have had all along.
"She was struggling to cope with the trauma therapy she was being given, and her cries for help – which were getting increasingly desperate – were ignored. It is a tragedy to know that her death was preventable.”
During the seven-day inquest the court heard how in the week before her death she had been found on three consecutive nights with a ligature around her neck and was expressing suicidal and self-harm ideations, just days after being placed on "prolonged exposure therapy" which involved her reliving the horrific experiences of being raped as a teen.
'Emma was utterly failed by Cygnet...'
On Thursday the inquest heard a root cause analysis completed after Ms Pring's death by an independent Cygnet member of staff said she "wouldn't have died if observation had been increased" after the incidents in the week before her death.
At the time of her death, the jury was told that Ms Pring was discovered 17 minutes after the final observation.
Cygnet policy requires intermittent observations must be completed within 15 minutes of each other.
The witness conducting the observations initially told the police that they attended 17 minutes after the final observation.
The family understands this was corroborated by CCTV and documented in Emma’s notes.
However, despite initially telling police they attended 17 minutes after the final observation, the witness told the inquest jury that they actually attended within 15 minutes.
The inquest also heard evidence that a risk management computer algorithm raised Emma’s risk level from “green”, which is low risk, to “red”, high risk.
Despite this, numerous members of staff told the inquest that they had not been made aware of these incidents or of an increase in Emma’s risk of harm.
On April 19, a multi-disciplinary team meeting was convened to discuss whether Emma’s trauma therapy should continue.
The jury heard that, despite the clear escalation in Emma’s risk of harm, as evidenced by the life-threatening ligature incidents, and her suicidal ideation and distress caused by the imaginal exposure phase of her trauma therapy, Cygnet staff decided to continue with the treatment and not increase observation levels.
Ms Pring's mother Caroline Sharp expressed she felt the incidents prior to her death were a "cry for help" and she didn't want to die.
Earlier in the inquest Tom Stoat, representing Ms Pring's family, explained how evidence from one of the nurses observing her on the night she died detailed how a partially filled out handover sheet meant she didn't know the level of risk surrounding Ms Pring or why she was being observed.
When questioned on whether paperwork was checked by senior members of staff, quality assurance officer Megan Johnston, from Cygnet, explained a monthly audit of four samples of paperwork was checked and were 90% compliant.
Mr Stoat expressed the family's concerns that they, as well as Ms Pring's lead practitioner Mark Oldham, were not told about the events from April 14 to April 16, which were cause for concern.
Ms Johnston explained that as the patient had not been injured and did not require hospital treatment the incident wasn't deemed "serious", which is when family and other close parties would be informed.
Last week jurors heard Ms Pring's mother, Caroline Sharp, describe her daughter as a "ray of light" who was a "loyal and generous person who puts others first" and had an "infectious smile and laugh".
A spokesman for Cygnet Hospital Maidstone said: "We would like to express our deepest condolences to Emma’s family and friends. Our thoughts are very much with them at this time.
“Following this tragic incident, we carried out an internal review to identify areas for learning and improvement.
"We also worked with the manufacturer of the anti-tear clothing to recommend improvements to the design and put strict protocols in place around the use of this clothing across our facilities.
“We take the safety and wellbeing of our service users extremely seriously, and the recommendations from our review have been shared locally and across the organisation to ensure lessons learnt are identified and shared.”
