Questions remain over mysterious death in mental health hospital

A mental health trust says it plans to install CCTV after a patient died under mysterious circumstances.

Maria Morris, 44, was found unconscious at Bethlem Hospital in south London on September 21, 2021, with four socks down her throat and a large unexplained bruise on her back.

She died hours later in hospital from a traumatic brain injury caused by lack of oxygen. The consultant treating her wondered if she had been attacked.

An inquest jury at South London Coroner's Court concluded her death was an accident, but her family say they still have questions about what led to her death.

The inquest heard that Maria Morris, who worked as a teaching assistant, suffered from bipolar affective disorder.

In September 2021, her family and friends became concerned when she began acting erratically and discovered she had stopped taking her medication.

Police were called after she ran away from a friend while walking in the park. She was delirious when found and was taken to Croydon Hospital.

On 18 September she was transferred to Bethlem Royal Hospital, a psychiatric hospital run by South London and Maudsley Healthcare Trust (SLAM), where she was admitted to a unit under the Mental Health Act.

The jury was told that while on the ward, Maria raised a number of concerns about the way staff treated patients. She told one of the staff that patients were “punished” at night.

On the evening of September 21, staff noticed Maria in her room at 8:00 pm and then again at 8:30 pm.

At 9:23 p.m., a staff member found her unconscious on the floor of her room due to cardiac arrest.

During attempts to resuscitate her, a sock was found in her throat. When paramedics arrived, three more socks were pulled from her throat.

By the time she was transferred to University Hospital Croydon, she had suffered hypoxic brain injury. A few hours later she went into cardiac arrest again and died on September 22.

The jury was told that Dr Simon Wood, an intensive care doctor at Croydon Hospital who treated Maria, told police there was a large bruise on her back.

He also said that he did not think the patient would have been able to stuff the socks down his throat without choking. He was concerned that this might indicate that she had been attacked.

The jury heard there was no CCTV in Bethlem Hospital's rooms and there was nothing in Mary's recordings or observations to explain the bruises.

When she was found, Maria's room was locked. The court heard most patients had keys to their rooms, but there was no record of who had which key.

The staff had master keys that could be used to open all patient rooms.

In a statement read to the court, DC Metropolitan Police officer Herdeep Jagdev said his investigation was hampered because Mary's room in Bethlem was cleared and a sock thrown away before they arrived there, 19 hours after her death was reported.

During the investigation, police noticed what appeared to be blood under Maria's fingernails, although it does not appear to have been tested to see whose blood it was.

John Taylor, the South London coroner, told the jury there was not enough evidence to conclude that Maria was attacked in the room or that someone else had stuffed socks into her airway.

The inquest heard conflicting testimony from Bethlem staff about how often Maria was checked on the night of her death.

Some documents and witnesses suggested that she should have been checked four or five times an hour. Others suggested that it should be checked once an hour.

The jury found that Maria had stuffed the socks down her throat, but that her death was an accident. They were unable to conclude whether the lack of sightings contributed to her death due to conflicting evidence.

In a statement, Mary's family said she was a much-loved mother, daughter and sister and that her death “has left a deep and lasting void in the hearts of her family and all who loved her.”

“We are grateful to the jury for identifying missed opportunities in communication, documentation and observation.

“As a family, the thought that more could have been done to keep her safe causes us great pain.”

The family also said they don't think jurors are allowed to comment on all the issues they consider important.

“As a family, we still have questions about what exactly happened that night.”

South London and Maudsley NHS Trust (SLAM) says it will install CCTV in all its branches and open a new CCTV control center in November.