Sunday 14 July 2024
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Nottinghamshire psychiatric hospital missed opportunities, inquest into woman’s death concludes

Nottingham Coroner’s Court concluded on Monday 18 July that there were missed opportunities by Millbrook Hospital in Sutton-in-Ashfield, Nottinghamshire, after a 31-year-old woman took her own life while in the hospital’s care.

  • Amelia Rose was found to have self-ligatured at the end of her bed at a psychiatric hospital in Sutton-in-Ashfield, Nottinghamshire
  • Inquest into her death found that Amelia did not receive the care she should have
  • Law firm Nelsons has been helping the 31-year-old’s family to find answers


Amelia Rose had been struggling with poor mental health for a few years when she was admitted to Priory Kneesworth House on 7 December 2019. While there, she self-harmed on at least two occasions, resulting in her being detained under section three of the Mental Health Act and transferred to Millbrook Hospital in Sutton-in-Ashfield on 28 January 2020.

Following arrival at Millbrook, a care plan was drawn up containing vital information about Amelia’s care, including regular, ten-minute observations. This plan was not read or followed by anyone on the ward.

Screenshot 2022 07 20 at 13.02.20
Amelia Rose, parents Yvonne and Graham Dooley, and sister Laura

In the early afternoon of 31 January 2020, Amelia told staff she was struggling and requested medication to help. However, as she’d already been given medication at around midday, a mental health nurse advised that further medication could not be given. Alternative medication could have been offered, but this did not happen, nor did staff offer Amelia any one-to-one support.

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At 1:50pm a healthcare assistant documented that Amelia was in her bed space and that the ten-minute observation had been completed. However, CCTV showed that, between 12:59pm when Amelia returned to her room from the communal area and 1:53pm when she was found, no observations were carried out. No one looked closely through the window into her bed space or entered her bedroom to carry out the relevant observations.

When a staff member did attend Amelia’s room, she was found to have self-ligatured at the bottom of her bed and was taken to King’s Mill Hospital where she passed away the following day on 1 February 2020.

The hearing was an Article 2 inquest – an enhanced inquest, which is held in cases where the state or ‘its agents’ (in this case, the NHS trust responsible for Millbrook Hospital) have failed to protect the deceased against a human threat or other risk or where there has been a death under some form of detention, such as the Mental Health Act.

The five-day hearing concluded on Monday 18 July 2022 at Nottingham Coroner’s Court. The jury found that Amelia most likely died by her own hands, but they were unable to determine her intent. They also outlined missed opportunities to deal with Amelia’s distress at the time leading up to her death and the coroner, Ms Bower, stated that Amelia did not receive the care she should have from staff at Millbrook.

Graham and Yvonne Dooley, the parents of Amelia Rose, said: “We take a little comfort from the conclusion and feel like some of our concerns have finally been listened to. Millbrook Hospital has provided some evidence to suggest that it is making the changes needed to ensure that what happened to Amelia doesn’t happen again. However, we feel that the multiple opportunities to help Amelia that were missed will stay with us forever.

“There were a few personal experiences that led to the deterioration of Amelia’s mental health and her admission to several hospitals all over the country. However, every time she was discharged, she was left with very little support, which meant that the circle would continue and she would inevitably end up back in hospital again.

“However, during the time she was in the community, Amelia lived at Hughendon Lodge, a live in support hostel provided by Framework, where she volunteered to help other residents who were also experiencing mental health issues – even though she was struggling herself.

“Despite everything she faced, our beautiful daughter was one of the kindest, most loving and caring people you could ever meet and the fact that hundreds of people attended her funeral is a testament to that. Amelia was admired, respected, loved and an inspiration to everyone that knew her.

“Amelia really wanted to get better, but she didn’t know how to cope. All she wanted was a fair chance at life but she was utterly let down by the people who were supposed to be keeping her safe.

“We know we can’t bring her back, but we don’t want Amelia’s death to be something that nobody learns from, or for other people to be unable to get the help they so desperately need. We have to be her voice now.”

Lucy Wilton and Rachel Benton, inquest specialists and solicitors at law firm Nelsons, have been assisting Graham and Yvonne, and barristers Rachel Young and Tom Herbert of Ropewalk Chambers also represented the family during the process.

Lucy said: “The inquest highlighted many concerns about missed opportunities in the period leading up to Amelia’s death. It is evident that she was experiencing serious mental health issues, but that she did not receive the care she required, especially on the day before her death.

“Amelia’s care plan stated that if she exhibited certain early warning signs she was often able to approach staff, but if Amelia was unable to do this due to high levels of distress, staff were to provide one to one support at the time. The fact that this was not actioned on 31 January when she told staff she was struggling and requested medication is just one example of Amelia being let down.

“A further missed opportunity was the fact that, despite Amelia being put under ten-minute observations, CCTV showed no staff visited her bedroom between 1.00pm and 1.53pm, when she was found to have self-ligatured.

“Monday’s ruling shows that Amelia did not receive the care she should have at Millbrook Hospital and opportunities to deal with Amelia’s distress were missed. Nothing can ever bring Amelia back to her family and loved ones, but they can only hope that lessons have been learnt which could help avoid the same things happening to somebody else.”

For more information on Nelsons’ involvement at inquests, please visit

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