Caroline Sharp believed that when her daughter Emma Pring was admitted for treatment at the private Cygnet hospital in Maidstone, it would be a turning point in her daughter’s life. “In some ways it was my naivety, but I really did think she was getting the best care,” Sharp says.
During the inquest to establish how and why her daughter died while an inpatient at the hospital, and after hearing the evidence given by the staff, Sharp remembers thinking: “How on earth did I let my daughter go there?”
Sharp says her daughter was fundamentally a “lovely, lively, cheeky little girl”.
“She was just so lovely to everybody she met,” she says. “And even when she started having her own difficulties, she just had so many friends that she would put over and above herself. I mean, just by looking at her Facebook page, the number of tributes and the number of people who still send her messages now, just really shows how she would always put everybody else first, often to her own detriment.”
The difficulties Pring experienced refers to the struggles she had with her mental health, which included depression, borderline personality disorder and PTSD which was triggered when she was raped twice at the age of 18.
In April 2016, Pring’s mental health began to further decline and she began to receive care from Sussex partnership NHS trust, left her job as a nursery nurse, and was eventually detained under section 3 of the Mental Health Act. In July 2020, Pring was transferred, by the NHS trust, to the Roseacre ward at Cygnet in Maidstone, for what was meant to be long-term, specialist treatment.
As a patient at the hospital, Pring received a type of trauma therapy which involved reliving what happened to her at 18, a therapy which Sharp said her daughter was “terrified” of beginning. In February 2021, although communication to her daughter was limited, Sharp says that a few days before her daughter’s death she told her mother that she wanted her to bring her home. “I said, Ems, you’re under a section 3, I’m not allowed. I can’t just do that.”
Pring killed herself on 20 April 2021, aged 29. An inquest into her death, which concluded last month, found it could have been prevented by the hospital, with the jury finding there had been an “insufficient level of observation, and a misjudgment of Emma’s actual risk”.
Rather than being placed on one-to-one observations that might have prevented her death, Pring was supposed to have been observed by staff every 15 minutes, a timeframe which the inquest found was not always adhered to. Cygnet’s own “root cause analysis” report found that if Pring had been placed on one-to-one observations it is likely that she would not have died. The coroner is also considering whether to issue a prevention of future deaths notice to Cygnet hospitals.
Her daughter’s death has also led Sharp to question why her NHS trust was unable to provide care for mental health patients themselves, rather than contracting beds at private hospitals. “Why aren’t the NHS able to [provide this care] themselves?,” Sharp asks. “Why are there no placements on the NHS? Why are we relying so heavily on private healthcare to provide something like this?’”
There have been at least 20 deaths of patients, aside from Pring, at Cygnet hospitals across the UK since 2011. Inquest, which has been tracking these deaths, believes they are concerning. Following the death of 17-year-old Chelsea Blue Mooney at a Cygnet hospital in Sheffield in April 2021, the same month that Pring died, an inquest found that “insufficient care” at the hospital had led to her death.
For Sharp, hearing the jury’s conclusion at the inquest, that her daughter’s death could have been prevented and that there were failures at Cygnet hospital was “difficult to process”. “It’s just, really really difficult to come to terms with, and to know, that your daughter was failed by the people that should have been looking after her,” Sharp says.
A Cygnet spokesperson said: “We would like to express our deepest condolences to Emma’s family and friends. Our thoughts remain with them.
“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.”
In the UK and Ireland, Samaritans can be contacted on 116 123 or email jo@samaritans.org or jo@samaritans.ie. In the US, the National Suicide Prevention Lifeline is 1-800-273-8255. In Australia, the crisis support service Lifeline is 13 11 14. Other international helplines can be found at www.befrienders.org.
Caroline Sharp was represented by Tara Mulcair at Birnberg Peirce, a firm which specialises in representing bereaved families in inquest proceedings.
