Inquest into death of nursery worker, 22, to begin

An inquest begins today at Wiltshire and Swindon Coroners Court into the death of a 22-year-old woman who took her own life whilst on a psychiatric ward in Swindon.

Carla Heaton, who was a nursery worker, was found unresponsive on 21st November 2022 in the Applewood Ward, where she was being treated.

She'd also played football for Cirencester Town before her mental health deteriorated and she began exhibiting tics which worsened over time.

A jury will be asked to consider whether there were failings by Avon and Wiltshire Mental Health Partnership NHS Trust in relation to Carla’s care during her time on the ward and whether appropriate levels of observations and mitigations were in Carla's care plan.

The family say they're keen to ensure lessons are learnt while also encouraging others experiencing a mental health crisis to ask for help.

Naomi Lawrence, Carla’s mother, said: “Carla was a privilege to have in our lives and there are no words which could properly express how loved she is and how sorely she is missed. It’s impossible to convey just how full of a personality she had and how brightly she shone on all our lives – from the sweetness and kindness shown in her role as a nursery practitioner, to her passion on the football field which was met with respect and love from teammates and opponents alike."

Family want answers to long-held concerns

Carla had been admitted to Applewood Ward more than months before her death.

During her time there, she made a number of ligature and self-harm attempts utilising both contraband materials and items located from an unlocked and unattended activity room on site.

For some time, her family had been concerned about the ongoing tics she'd developed and the injuries she suffered as a result, as well as concerns about a change in her behaviour prior to her death.

They have further concerns around how her tics were managed, whether risk assessments were carried out and updated properly, how medication and observations were monitored, conducted and recorded and whether appropriate observations were done.

They want answers as to why Carla was able to continuously fund and use items for deliberate self-harm, despite the known and ongoing risk she posed to herself.

Just days before she died, Carla absconded from the ward and was returned by police. She was detained from 18 November onwards under s3 of the Mental Health Act.

In her final days, the family say Carla kept expressing a desire to end her life. She was found not breathing just after midday on 21st November and was unable to be revived.

Ms Lawrence said: “Carla was always open and aware of her emotions and challenges, and I feel heartbroken that I feel she was let down by her openness not always being taken seriously by others. She was someone who cared deeply about helping others and not wanting to upset people or be a burden, and she went through every means possible to try and get help managing her tics once they developed.

“I welcome the opportunity for the jury to consider the circumstances around Carla’s death and treatment while admitted to Applewood Ward. Ensuring everyone has access to help if they need it is a vital part of our healthcare system and those who require help should seek it out.

“However, there is a need to make sure care is done with the person in mind, not the statistic. I hope that this inquest helps shine a light on the final days of Carla’s life and consider whether the actions taken in the process of her care were sufficient and did everything they could to support Carla’s mental health at the time.”

Avon and Wiltshire Mental Health Partnership NHS Trust says it won't comment during ongoing proceedings.