Mirren Gidda was instructed by Goksel Karova of Attwater Jameson Hill solicitors to represent the family of Margaret Mary Picton, known as Rita, who, in the early hours of 10 September 2022, was taken to Leigh Moss Hospital in Liverpool under section 3 of the Mental Health Act 1983. Rita displayed escalating behaviours throughout that day, culminating in several instances of her attempting to eat paper in full view of staff. Rita ultimately choked on the paper and later died in hospital.
Helen Rimmer, Assistant Coroner for Liverpool and the Wirral, heard the inquest over five days and handed down her conclusion after careful deliberation on 5 February 2025. She found that Rita’s death was contributed to by neglect and that “there were insufficient processes in place to ensure appropriate allocation and handover of responsibilities”. The Coroner further found that “there was a failure to adequately monitor Rita, observations were missed, and there were failures in appropriately escalating concern in accordance with policy”.
During the inquest, the Coroner heard that Rita, who had a history of mental health problems, began to deteriorate in early September 2022, such that the care home looking after her felt it could no longer safely do so. A Mental Health Act assessment was undertaken, and Rita was sectioned and taken to Fern Ward within Leigh Moss Hospital. Staff at Fern Ward had assessed that Rita would require Level 2 observations, meaning observations spaced no more than 15 minutes apart. Rita would also be observed by staff conducting zonal engagements of the area she was in.
On the day Rita was admitted, Fern Ward was short staffed with eight staff on duty instead of the required 10. The Coroner found that Rita’s presentation fluctuated throughout the day and she became more agitated and aggressive, including displaying behaviours indicative of self-harm and general distress. The Coroner found that there were “missed opportunities to properly escalate Rita’s concerning behaviours and for consideration to then be given to whether Rita required 1:1 observations or in the alternative to ensure that appropriate level 2 observations were being undertaken”.
The Coroner found that from 18:00 to 19:00, Rita’s Level 2 observations were not conducted in line with Mersey Care NHS Foundation Trust’s standard of competency and that her zonal engagements were not completed in line with Trust policy. The Coroner identified this as “a missed opportunity to identify a deterioration in Rita’s behaviour and presentation and escalate concerns”.
The Coroner found that from 19:00 to 20:00, Rita’s Level 2 observations were not completed at all due to a communication breakdown and neither were her zonal engagements. The Coroner found that “this was fundamental basic care and supervision, which more likely than not would have led to an escalation and review of Rita’s behaviour and presentation at that time had the requisite observations been undertaken.”
From 19:00, CCTV footage shows Rita in the ward’s dining room attempting to put paper into her mouth five or possibly six times. The Coroner found that staff in the area did intervene at some of these times but did not escalate Rita’s behaviours. Staff also failed to establish whether all of the paper had been removed from Rita. During a later incident of paper-eating, the intervening staff member did not remove any of the paper from Rita and then sat with his back to her, so he did not see her again put paper into her mouth. The Coroner found that “these were missed opportunities to provide basic care and support to Rita”, despite staff being aware of the choking risk of eating paper. The Coroner found that had staff been appropriately observing and supporting Rita or escalated concerns about her, “this would have more likely than not prevented Rita from eating paper and subsequently choking”.
The Coroner found that when Rita choked and collapsed, staff who had seen her eating paper did not immediately report this to the staff members providing CPR and so choking prevention manoeuvres were not considered. Instead, CPR had been ongoing for approximately 25 minutes and Rita had gone into cardiac arrest twice before attending paramedics were told that she had been eating paper, which they were then able to remove. Rita was subsequently taken to the Royal Liverpool University Hospital where she later died of aspiration pneumonia caused by the paper eating, the resuscitation efforts that followed, or a combination of both. The Coroner found that removing the paper was “basic care and treatment that should have been undertaken and raised sooner”. She further found that “not to have provided this basic care and information to professionals treating Rita was a gross failure which more likely than not hastened Rita’s death.”
The Coroner stated that having identified a specific gross failure amounting to neglect, she also found that “the accumulation of the catalogue of missed opportunities throughout the care of Rita by those involved in her care at Leigh Moss Hospital, namely the acts and omissions mentioned above, have as a whole also amounted to neglect.”
Mirren Gidda is a member of No5’s Public Law group. She is taking instructions to represent families in inquests.
