DISMAYED relatives of a woman who died while being supported by a health trust have told of their shock at a report highlighting failings in their loved one’s care before her death.
Troubled Sheriden Harris, 20, died in May last year when she was run over by a taxi while on a boozy night out with friends in Portsmouth.
But findings of a probe by Southern Health NHS Foundation Trust released to her grieving family – and seen by The News – highlighted a catalogue of errors by officials looking after her in the run-up to her death.
Among them included a failure for health bodies to communicate with one another after Ms Harris’s mental health took a worrying turn for the worse months before she died.
Southern Health has since apologised for the errors in Ms Harris’s care plan and vowed to make improvements.
However, the health giant claimed the failings identified by the report did not directly contribute to Ms Harris’s death.
But the 20-year-old’s aunt, Claire Mastin, criticised Southern for not letting her family play a more influential role in Sheriden’s care, which the family argued could have saved her life.
The 39-year-old, of School Lane, Havant, said: ‘Sheriden has been failed by the system.
‘We were never told anything about her issues while she was in care.
‘We’re her family and we would have wanted to help her but we just had no idea, they never told us. We were left in the dark.
‘Sheriden could have been alive today if we had been involved in her life.
‘She was family and we were just ignored. That’s disgusting.’
At the time of Ms Harris’s death, she had been staying at a care home in Kiln Road, Fareham, which was managed by Choice Care Group.
She moved there from Portsmouth in May 2016 after a referral to East Hampshire Community Learning Disabilities Team (CLDT) by Portsmouth Learning Disabilities Team the month before.
However, following this move, the 32-page report identified failings in clinicians to pass on key information about Ms Harris’s mental health issues. which had escalated to a worrying level in the months before her death.
The 20-year-old, who had learning difficulties, had begun to self-harm, hurting herself on several occasions between February and April, 2017.
She even attempted to take her own life, the report said, by overdosing on pills, a month before her death.
Ms Harris told staff she had started to ‘hear voices’ and ‘see shadows’ and that her alcohol abuse had begun to escalate.
The situation sparked an adult safeguarding alert and crisis meeting by care home staff.
However, the report said that staff felt changes in Ms Harris’s behaviour weren’t being ‘taken seriously’ by East Hampshire CLDT and that there was no coordination between mental health support services.
The report also found concerns about Ms Harris’s booze-fuelled social trips were not passed on to officials.
When she died, she had been drunk and was laying in the middle of the road – a behaviour that had been previously identified in a risk assessment but that had been missed by health officials.
Sheridan’s cousin Amelia, 18, is a support worker and was sickened by the results of the investigation.
‘This just breaks my heart,’ she said. ‘It brings a lump to my throat.
‘The people I support have learning difficulties and mental health issues. We support them to the very best of our ability.
‘But in the home that she lived in they didn’t support her emotionally. She was crying out for help.’
Southern Health investigating officer Nic Cicutti, apologised to the family in a letter, which has been seen by The News.
He wrote: ‘I unreservedly apologise to you, as Sheriden's next-of-kin, and all other members of her immediate family for our mistakes.
‘While my report does not find that our care and service delivery failures caused Sheriden to die or directly contributed to her death on May 12, 2017, there are some very serious lessons for us to learn from.’
He added the report found a ‘a number of failures’ on the part of Southern NHS Foundation Trust to deliver the care Ms Harris had ‘the right to expect’.
He said: ‘We did not provide Sheriden with integrated, joined-up care between our learning disability and mental health teams and failed to make use of a care programme approach that could have brought together all agencies and professionals involved in supporting her.
‘Basically, we failed to communicate with each other properly.’
Fareham MP Suella Braverman is organising a time to meet with the family.
She said: ‘This is a tragic loss of life, we must think of Sheriden’s family and friends at this time.
‘It highlights the need for serious and meaningful change to ensure more patients are not failed, and to protect the most vulnerable.’
Health trust makes ‘improvements’
SOUTHERN Health NHS Foundation Trust has said it has learned from mistakes in caring for a woman with learning difficulties who died while in their care.
The health body said it has worked hard on addressing failings identified by a report following the death of Sheriden Harris in May 2017.
Ms Harris died on a drunken night out after being hit by a taxi while she was lying in the middle of the road in Portsmouth.
And although the trust said the failings highlighted by the probe had no direct relationship to Ms Harris’s death, officials admitted they have since made improvements to their services.
A spokesman for Southern Health said: ‘The trust has made improvements to the care we provide which have recently been acknowledged following inspections by the Care Quality Commission.
‘For example, we are now rated “outstanding” for our learning disabilities inpatient services.
‘We are working hard to keep improving our services to make them the best they can be and this is an ongoing task.
‘The learning from this incident has been shared and plans undertaken to embed improvements.
‘We work hard to involve families in the care of their loved ones wherever possible, whilst respecting individuals’ wishes about their confidentiality.’
Report recommends changes to health services to avoid future tragedies
RECOMMENDATIONS have been made to improve health care following the death of Sheriden Harris.
A report by Southern Health NHS Foundation Trust into the 20-year-old’s death highlighted a number of failings in care systems.
The investigation recommended that adult mental health and learning disability services ‘explore options’ to work closer together and establish regular communications when people with learning disabilities are referred to adult mental health services.
Adult mental health and learning disability services are also being urged to review procedures in dealing with complex patients and that clinical staff understand the care programme approach in dealing with service users who present with high risks.
A recommendation has also been made for East Hampshire Community Learning Disabilities Team to review processes used to actively pursue needs, risks and clinical management information when patients transfer into its locality.
Finally, better processes and communication is needed for managing users who move into the area from elsewhere.
1) There was a missed opportunity by East Hampshire Community Learning Disability Team (CDLT) to make ‘full use’ of information provided by Solent NHS Trust’s Learning Disability Service during the transition phase of Ms Harris’s move from Portsmouth to Fareham.
Records of Ms Harris’s treatment history and risk profile, by Solent NHS Trust, were on East Hampshire CLDT’s shared computer drive. However, clinicians were unaware of these files.
2) There was a failure to use the care programme approach, a core process used in the care of people with learning disabilities who present complex physical and behavioural needs.
3) There was a failing to follow adult mental health screening and assessment process by the mental health practitioner in Gosport and Fareham CMHT.
4) Fareham and Gosport CMHT discharged Ms Harris on April 26, 2017, after she walked out of a key emotional skills coping session. No formal record of this was made.
5) There was no recorded plan to follow-up, monitor or review Ms Harris’s mental health medication prescribed by a psychiatrist in Fareham and Gosport CMHT on March 30, 2017, following an episode of ‘disturbed behaviour’ by Ms Harris.
6) There were communication failures between East Hampshire CLDT, Solent NHS Trust learning disability services and the care team at Kiln Road which meant that information about Sheriden’s risk behaviours when going out at night were not shared and discussed among all professionals in her care.