Rachel Garrett Inquest: Missed Opportunities in NHS Mental Health Services to Save Young Woman’s Life

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Rachel Garrett, from Hove, was 22 years old when she died after falling from cliffs near Brighton Marina on 29 July 2020. She had been in crisis and had both mental and physical health needs, including cerebral palsy.  

At an inquest in Brighton which concluded on June 2 2023, HM Coroner Penelope Schofield delivered a narrative conclusion, saying that there had been missed opportunities to save Rachel’s life. 

Throughout the two-week hearing, evidence was heard that Rachel’s death was her sixth suicide attempt in just four weeks. Her family – who describe her as a courageous, fun, sensitive, loving person who made friends everywhere she went - had been desperately fighting to get her readmitted to a secure mental health ward for treatment and support. 

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Speaking at the hearing Dr Laurence Mylor-Wallis, an independent psychiatric expert, identified three missed opportunities to protect Rachel prior to her death. 

During the hearing, he told the inquest that, in his opinion, there should have been a detailed plan in place to protect Rachel, adding that this could have either been in hospital or in the community. 

He added that ‘one of the facts that clinicians needed to weigh up was the parents' views and they were extremely worried’, saying that ‘their views absolutely needed to be taken into account in whether she needed to be detained or not’. 

On 17 July, Rachel was found by members of the public on a clifftop, and police and a mental health nurse attended the scene. While in handcuffs and being restrained by three officers, she kicked the mental health nurse, was arrested, and taken into custody. 

Whilst in custody, Rachel self-harmed despite being under constant observation. An Accident & Incident Report recorded that this was ‘to get more attention rather than a genuine attempt at suicide. ‘Rachel was released three days later despite her parents' expressing serious concerns about her safety and their ability to keep her safe.  

However, despite their concerns, on 28 July, Rachel was taken to Royal Sussex County Hospital – instead of Mill View Hospital, a hospital for adults with mental health problems - after being found on a clifftop.  

When Rachel’s mother arrived at the hospital, she was not allowed to see Rachel. She told the mental health nurse who had attended the clifftop how worried she was about Rachel’s safety if she was not sectioned under the Mental Health Act, and requested that a Mental Health Act Assessment be carried out if she wasn't. 

Despite junior officers expressing their concerns to senior colleagues about Rachel's safety if the police left the hospital, the inquest heard how the police sergeant in charge said he was “willing to take the risk” and instructed them to leave the scene. 

At 12.23am on 29 July, Rachel absconded from the hospital. She was found by police shortly afterwards and taken home. Again, her parents asked police for Rachel to be sectioned but instead she was taken back to A&E for a mental health assessment. 

Rachel was placed under one-to-one supervision by a healthcare assistant, but despite demonstrating the mounting evidence of increasingly risky behaviour Rachel was able to leave the hospital again. 

She was reported missing to police at 3.47pm. The hospital did not contact her parents. Giving evidence, the independent psychiatric expert identified this hospital stay as the third and final missed opportunity for Mental Health Services to save Rachel’s life.

An hour later, Sussex Police located Rachel on the same clifftop as the previous day. Police officers and a mental health nurse approached to talk to her, and she edged closer to the cliff edge. Rachel fell from the clifftop, and was declared dead at 6.03pm. 

An extract of Rachel's diary which was read to the court during the inquest, she had written: "I am rapidly deteriorating… I don't understand how bad you are supposed to get before they help you?"

Mental Health Services ‘Contrary to Common Sense’

During the hearing, Sussex Partnership Foundation Trust said that staff working in the A&E department did not have the necessary power to invoke Section 5 of the Mental Health Act, which allows for temporary detention of an informal or voluntary service user on a mental health ward. 

Following the conclusion of the inquest, coroner Penelope Schofield has vowed to write to NHS England to raise concerns about the issue which affects NHS Trusts and patients across the country.  

Speaking following the inquest Rachel’s parents, Sarah and Andy Garrett, said that they felt that the Mental Health Services in Brighton and Hove had played ‘Russian Roulette’ with Rachel’s life. 

Lawyer Chris Callender from Simpson Millar, instructed by the charity INQUEST which supported the family during the hearing, added that it was ‘contrary to common sense’ that a highly distressed young person can be permitted by mental health services to repeatedly undertake extremely high-risk visits to a cliff edge, and not be contained and treated’. 

He said that a failure to put an appropriate care plan in place much sooner had proved fatal for Rachel, and that her family continue ‘to pay the price’. 

Rachel’s Parents Say Their Concerns Were Not Heard by NHS Trust

“Too much emphasis has been placed on the day of Rachel’s death, yet in reality, we had been desperately seeking help for many months, looking to the relevant authorities to provide a comprehensive plan of action that would meet her needs.  

“As her behaviour became increasingly risky, she should have been admitted to a secure mental health ward for treatment and support. 

“Instead, we feel Sussex Partnership NHS Foundation Trust spectacularly failed to take into consideration all of the risk factors when assessing Rachel. As her parents, they should have also taken into consideration our concerns when making decision. We should have been heard, but we felt we never were." 

  • "We feel that in July 2020, the Mental Health Services in Brighton and Hove played Russian Roulette with our daughter's life. "

    Sarah and Andy Garrett

    Rachel's parents, following the conclusion of the inquest

The family is now supporting Martha’s Rule, a new campaign to ensure patients and those closest to them are listened to and that their views are taken into account by healthcare professionals.

Chris Callender, Public Law expert here at Simpson Millar who represented the family at the inquest, said: 

“The evidence that has been presented throughout the inquest with regards the care that she received, and the many, many missed opportunities to take action has been extremely difficult for them to hear.  

“Tragically, for Rachel, that failure to put an appropriate care plan in place much sooner proved fatal, and her family continue to pay the price. 

“Sadly however, they have found that they are not alone in their grief, and that many other families have also been impacted as a result of mental health services failings – both in Sussex, and across the country.  

  • "It is their hope that genuine lessons are learnt by both the police and Sussex Partnership NHS Foundation Trust further to the conclusion delivered by the coroner, and that changes are put in place urgently so that people in crisis can access the care and support that they need, when they need it most."

    Chris Callender

    Public Law Solicitor

Caroline Finney, Caseworker at INQUEST, said:

“Rachel was repeatedly failed by the services tasked with keeping her safe. Like so many other young women, her distress was dismissed and ignored to the extent that a police officer was willing ‘to take a risk’ on her safety. 

“Her death will be added to the long list of young women who died trying to access support. Their stories must be the wake-up call that leads to investment in non-punitive mental health care and crisis intervention teams, delivered with and by communities.” 

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