Before Coroner for Inner North London, Dr Shirley Radcliffe
Westminster Coroner’s Court, 65 Horseferry Road, London SW1P 2ED
16 July 2018 – 24 July 2018 
 
The inquest into the death of Sophie Payne concluded yesterday, with the jury finding a series of significant failings contributed to her self-inflicted death. Sophie was 22 years old, and a much-loved daughter, sister and friend. She was warm, bright and creative, and enjoyed writing poems and supporting others. She had worked as Youth Worker and planned to go to university. 

On 27 July 2017, Sophie was found unresponsive with items in her throat whilst detained as a mental health patient on the Rose Ward at Queen Mary Hospital in Roehampton. Earlier that same day, Sophie had made another serious attempt to take her life in the same manner.

The jury found that there were a number of failings in Sophie’s care that contributed to her death, including:

• Failure to generate incident reports following multiple incidents of Sophie self-harming in the same high risk manner.
• Failure to review and update Sophie's risk assessment.
• Failure in care planning and failure to update Sophie's care plan after significant incidents.
• Failure to carry out a multi-professional meeting, leading to a missed opportunity for a more comprehensive plan for Sophie's care.
• Failure, on the day of her death, to remove items from her room which posed a risk (despite removing other items).

Sophie first came to the attention of mental health services as a teenager following a sexual assault, and subsequently experienced post-traumatic stress disorder, bipolar disorder and emotionally unstable personality disorder. She had been admitted to hospital approximately 24 times in the four years before her death.

On 3 July 2017, she was readmitted to the Rose Ward. Her mental health had deteriorated around the anniversary of a friend’s death. In the following three weeks she made a series of serious acts of self-harm. The inquest heard how Sophie had said to her father, Mike, and his partner, Maria Martin, that “they are not taking care of me” whilst on the Rose Ward.

On 27 July 2017, Sophie’s father and Maria visited Sophie around 4:15pm. They were informed that she had been found unconscious in her room with a ligature and an item in her throat. She had been given two injections afterwards, to calm her down, and was acting ‘groggy’. When they left Sophie later that day, they believed that she was under 24-hour supervision, and would be safe. During the 8:45pm observations, Sophie was found again with items in her throat, but this time without a pulse.  

Mike Payne, father of Sophie said:"Sophie was a warrior. She fought her illness for many years but in the end, she lost the battle.

In her last four years she spent many periods in and out of different acute psychiatric wards. In our experience, the level of care she received during her final admission on Rose Ward was by far the most inadequate. Her care plan was almost non-existent. Less than 10% of self-harm incidents were reported and her overall care smacked of complacency on several levels.

We are so disappointed that the ward's communication with us was so poor. We were not informed of any incidents of self-harm, which we have learned about during the inquest, except those on the last day of her short life.”
 
Merry Varney, of Leigh Day solicitors said: “We welcome the jury’s damning conclusion highlighting the failures in Sophie’s care which contributed to her death. 

The inquest process has helped our clients understand more about what went wrong in Sophie’s care during her final admission, however it has also highlighted how much they were not told about at the time, despite Sophie clearly saying she wanted her father and Maria involved in her care.

The issues of concern in Sophie’s care range from internal reporting, to access to the treatment she needed, as well as individual risk assessment and care planning and it is imperative the Trust takes the broadest approach to reviewing the jury’s findings and improving care for other patients. This is what Sophie would have wanted.”
 
Deborah Coles, director of INQUEST said: “We are increasingly concerned about the repeated patterns of failure in the treatment of vulnerable women like Sophie in secure mental health care. All the warning signs were there, but yet again she was failed by the very systems that were meant to keep her safe. 

Recent research has found that four out of five teenage girls who have been sexually assaulted are suffering from mental ill health. For Sophie, this persisted into early adulthood. 

There is clearly a gulf between addressing the needs of women like Sophie, and the resources provided to care for them. To prevent future deaths it is essential that specialist, trauma-informed and women-centred treatment is available.”

ENDS

NOTES

INQUEST has been working with the family of Sophie Payne since August 2017. The family is represented by INQUEST Lawyers Group members Merry Varney of Leigh Day Solicitors and Sam Jacobs of Doughty Street Chambers.

For further information, please contact Sarah Uncles at [email protected] or 02072631111.

Other Interested Persons represented in the inquest proceedings were South West London & St George Mental Health NHS Trust and Mrs Julia Penfold, Sophie's mother.

• Research released in July 2018 has found that 80 percent of teenage girls suffer serious mental illness after sexual assault.
• In 2014, the Care Quality Commission published an inspection report on Queen Mary’s Hospital raising many of the same issues covered during Sophie Payne’s inquest.