22-year-old who died on mental health ward took own life, jury concludes
Carla Heaton died at Applewood Ward in November 2022
Last updated 24th Aug 2026
An inquest has concluded that a 22-year-old woman who died whilst on a mental health ward in Wiltshire took her own life.
Carla Heaton was receiving care at Applewood Ward for physical and verbal tics that she'd developed before her death on 21st November 2022.
A jury returned its conclusion following a seven-day inquest at Wiltshire and Swindon Coroners Court in Salisbury.
The court had been told that Carla's family were worried about the care she was receiving after being admitted to the ward in September 2022 following a deterioration in her mental health and ongoing tics, which were so severe that they caused her harm.
While she was on the ward, Carla had found items with which to harm herself, which were contraband contraband materials and items located from an unlocked and unattended activity room on site.
She was found unresponsive shortly after midday on 21st November and was unable to be saved despite the efforts of paramedics.
Risk conversations not recorded properly
Staff from Avon and Wiltshire Mental Health Partnership (AWP) told the jury that they relied on Carla to reveal to them items she'd used to self-harm, telling the court that room searches or removing these items was overly restrictive on the independence of patients.
They accepted that they'd failed to update the level of risk around Carla and not effectively recording conversations around risk and risk management, despite it being a key part of their own internal policy and guidance.
A neurologist who'd seen Carla before she'd been admitted to hospital in July, admitted he regretted that he'd been unable to build a therapeutic relationship with the family.
A meeting between Dr Graham Lennox and Carla lasted only a few minutes before she walked out. He accepted that his consultation with Carla had been clouded by his own academic interest in the subject.
Family grateful but frustrated
Carla's family says they still have many unanswered questions.
In a statement, Carla's mum, Naomi Lawrence, said: : “We are lost for words as to what has happened to Carla and the circumstances in which she died, and we cannot fully convey what her loss means to not just our family, but those groups and people she was so lovingly involved with – from her teammates on the football field to those she worked with and showed kindness and care to in her role as a nursery practitioner.
“We have waited close to four years to have the inquest into Carla’s death heard by the Coroner, and while we are grateful to the jury for their attentiveness throughout the inquest and the time they took to listen and consider the evidence, we are frustrated our concerns about her care remain unaddressed.
“Carla went to Applewood Ward to get help for her tics and her mental health and was meant to be kept safe, however she was able to consistently self-harm and ultimately took her own life with items that were accessible to her on the secure ward.
“We are frustrated AWP staff did not follow policy for completing risk assessments and care plans, including not identifying her key risk of self-harm and how that would be managed by staff. These plans were also not updated when she deteriorated. Staff gave evidence that removing items from her room that were ligature risks would have been too restrictive, but we believe with her increasingly concerning behaviour and stated desire and plan to meet her father who had died, removing plastic bags and items of cord from her room would have been sensible and may have saved her life.
“While Carla showed immense courage to attempt to manage her tics and mental health in every way she could, we wish that her needs were fully understood and respected by those in a position of care. While we thank the Coroner and the jury for their commitment to attempting to uncover the full events of what happened and understand key learnings to ensure no family ever has to go through something like this again, in our opinion she was let down time after time in her attempts to treat her tics and mental health challenges, and her loss has an immeasurable impact on all of us who loved her dearly.”
A spokesperson from Avon and Wiltshire Mental Health Partnership NHS Trust said: “We are profoundly sorry for the failures in Carla’s care that contributed to her death. Our heartfelt condolences remain with Carla’s family and loved ones, and we recognise the deep and lasting impact of their loss.
“Since Carla’s death in 2022, we have strengthened our procedures to reduce risks and improve safety on our wards and remain committed to sustaining those changes across our services.”
If you, or someone you know is suffering with their mental health, or experiencing suicidal thoughts, you can speak to your GP. If someone's life is in danger - call 999 immediately.
You can also find help and advice from these services:
Hub of Hope - https://hubofhope.co.uk
Samaritans – Call 116123 - https://www.samaritans.org
Mind - 0300 123 3393 - https://www.mind.org.uk