Inquest into Shannara Donnelly death at Chase Farm Hospital

Shannara Donnelly, 22, was considered at risk of self-harm and was meant to be watched "at all times" while at Chase Farm Hospital in Enfield, north London.

However, medical staff wrongly observed Ms Donnelly, who was known as Jade, by watching CCTV cameras - and missed her collapsing to the floor in her room at the unit.

So when nurses saw her on the ground they presumed she was sleeping, inquest jurors were told. She lay unresponsive for over an hour.

The inquest, held at George Meehan House in Wood Green, north London and expected to last up to two weeks, heard Jade died "apparently [by] her own hands".

Jurors heard her condition meant she required "one-to-one" care and continuous observation "24/7, seven days a week".

Shannara Donnelly, 22 (Image: Courtesy Donnelly family / SWNS)

The director of Barnet, Enfield and Haringey Mental Health NHS Trust has issued an apology to Jade’s family and admitted "shortcomings" in her care.

The court heard on Tuesday that despite a note on her health documents stating she shouldn't be sent to Chase Farm Hospital following a previous incident, Jade was again admitted to the unit after previous stays at St Ann’s Hospital in Haringey.

Just days before her readmission she had been arrested after threatening to harm herself and telling police officers she "wanted to die", jurors were told.

Area Coroner Tony Murphy read admissions from the Barnet, Enfield and Haringey Mental Health NHS Trust, including that Jade "shouldn’t have been sent" to Chase Farm Hospital, that her risk assessment was inadequate, and that she "should have been within eyesight observations".

The trust further admitted that necessary safety checks were not carried out by nursing staff at the facility, which was also housing another patient at the time, and that CCTV observations by staff were an inadequate form of observation.

Additionally, no staff on shift were compliant with their life support training and of the two oxygen tanks kept at the unit, one was empty and the other missing an essential attachment.

Jade's mother, Kerry Donnelly, told the court in a tribute to her late daughter that she'd been born at Chase Farm Hospital, as well as it being where she tragically died.

Shannara Donnelly, known as Jade, was considered at risk of self-harm and was meant to be watched 'at all times' whilst at Chase Farm Hospital in Enfield (Image: Courtesy Donnelly family / SWNS)

The family say they were shocked to be told Jade had died "apparently [by] her own hands", saying their interactions with her on the day of her death "[didn't] seem to fit" with someone who wanted to take their own life.

Prior to her death, a doctor had refused to discharge Jade from the unit, which had greatly angered her.

Ms Donnelly explained that her daughter had been diagnosed with ADHD and that she'd home-schooled her for a time, having been bullied at school.

She later attended Winchmore and Enfield County schools and became a "very popular girl with many friends".

The inquest heard Jade was an active member of both the Army and Police cadets, as well as being a member of the Royal British Legion.

"Jade always liked doing different things and whatever she did she generally put her heart and soul into it," Ms Donnelly said of her late daughter.

"Jade was a very special person and somehow people were just attracted to her. Jade loved to laugh and even more loved to make other people laugh.

"To Jade, all life was important and special. Jade loved her family and friends, and she would do anything for anyone sometimes even to the detriment of herself."

Ms Donnelly explained that Jade had struggled during lockdown and had recently lost three close members of her family before her death.

"The pain was sometimes just too unbearable for her," she continued. "As such, she had stayed in different places whilst she tried to get help and where she would be safe.

"Tragically, whilst in [the care of Chase Farm Hospital] on June 19, a very beautiful leaf fell from our family tree, but the memories of Jade will remain deep-rooted in our hearts forever."

CCTV footage played to jurors from the day of Jade’s death showed members of staff observing the girl on cameras and through 'peephole' windows, but not completing observations required under her level of care.

Mark Pritchard, Managing Director at Barnet, Enfield and Haringey Mental Health NHS Trust, began his evidence by apologising to Jade’s family.

“I want to offer my sincere condolences, on behalf of the Trust, for the shortcomings in Jade’s death,” he said.

Mr Murphy took the court through the Trust’s policy guidelines for patients under Level Three care, which Jade was under, which states they should be within sight ‘at all times’.

Guidelines also stated that though CCTV observation could be used to support staff, "it should not be used in place of observations and engagement".

They also stated patients should be observed "attentively".

Mr Murphy asked Mr Pritchard: “Does it appear to you that, during the footage you saw, that Jade’s observation was conducted by staff attentively?”

“No, I don’t believe it was,” the latter replied.

Jade’s family’s lawyer, Ross Beaton, later questioned Mr Pritchard on whether Jade's level of care was provided effectively.

Mr Beaton said: “Level Three means being within eyesight unless [the patient] is in the bathroom, in which case you will be in verbal contact [with them].

“Did you see any Level Three observations [in the CCTV footage]?”

Mr Pritchard replied: “The bulk of it, I would say no… The overarching answer is no.”

Jane Basemera, Jade’s allocated nurse on the day of her death, told the court the patient would have lived had she been on Level Four observations.

Ms Basemera, who broke down in tears during her evidence, said: “If a patient has [tried to use a] ligature, it should be arm's length [Level Four care].

"Arms length observations would have saved Jade."

Mr Murphy said: "It does appear that some very significant events that occurred to Jade during the time in the bathroom were missed."

Ms Basemera accepted that this was true, but also spoke of staffing issues at the unit, saying Jade should have had two nurses looking after her.

The nurse admitted she'd been told that Jade was on the floor, but hadn't been told of her collapse.

If she had been told, she said she would have known "without a doubt" that something was wrong, the inquest heard.

The inquest also heard that Jade had reported previous sexual abuse, had struggled with alcohol abuse and sometimes heard "voices" in her head.

The inquest continues.