An inquest into the death of a 20-year-old woman found unresponsive in her room at a mental health clinic has started.
Molly-Star Kirk was pronounced dead in her room at the Farndon Unit in Newark on May 29, 2022.
Her death is being treated as unexplained, however, the inquest heard that staff at the mental health clinic failed to conduct the required number of checks on Molly before her death.
The inquest started at Nottingham’s Council House on Monday (April 15) and is expected to last for ten days.
Coroner Laurinda Bower said Molly had been in long time in care, from 2017 to her death in 2022.
During that time, she attempted suicide several times and was admitted to several hospitals across the country including Milton Keynes, London, Maidstone, Northampton and Newark.
She had been an inpatient at the Farndon clinic, operated by Elysium Healthcare since October 2021, detained under Section 2 of the Mental Health Act.
The inquest was told that Molly was meant to be checked 12 times an hour, equivalent to once every five minutes, however, staff at the unit failed to do so during her final hours.
Molly was staying at the Aster ward, at the Farndon unit until her death. Aster ward is a shorter-stay stabilisation service for women that focuses on phase one trauma work, psycho-education and safety.
Molly was admitted to the unit to manage her mental health diagnoses and because she could not safely be treated in the community.
During her admission she experienced seizures, which were understood by staff to have been caused by Non-Epileptic Attack Disorder, as well as other health issues arising from self-harm.
Molly had previously been tested for epilepsy which the doctors didn’t confirm.
The 20-year-old was under several different medications to manage her mental health conditions, which included post-traumatic stress disorder, emotionally unstable personality disorder and bulimia nervosa.
Molly was last seen outside her room the night she died, as she did not come out of her room the next day, said to have refused her morning medication and lunch, which staff said to be unusual for her.
Due to her care plan, staff should have checked on Molly about 180 times between midnight on May 29 and 3pm the same day.
Records and CCTV cameras show that only 78 checks were conducted, with her being checked as short as three times per hour, several times during that time period.
According to Bhatt Murphy Solicitors, who are representing the family in court, another patient reported that Molly had been feeling unwell the day before she died.
Molly-Star was last checked at around 2.10pm, after which she was not observed again until she was found unresponsive by a staff member at about 2.30pm.
Paramedics arrived, however, Molly was pronounced dead shortly after.
The court heard that Molly had four to five seizures the day before she died and even made a 999 call to report it.
The emergency services were told on another call soon after not to send an ambulance.
A recording of the 999 call made by the staff member who reported Molly’s unresponsive state was played in court and showed that the staff was unsure about Molly’s age.
It was heard that the dispatcher was asking several times if Molly was breathing, if CPR was taking place, if there was a defibrillator at the unit, but the responses were vague or none at all.
Molly was described by her family as a bright and chatty girl, who was happy and loving despite the challenges she faced with her health issues. She was said to be family oriented and loved listening to music.
The inquest continues.
