Staff at Chesterfield mental health clinic could not have averted death of 20-year-old woman, inquest finds

Chesterfield Coroner’s Court heard that Leya Clephane-Lewis, 20, died at Chesterfield Royal Hospital on August 17 2020.

Leya, originally from Lincoln, was an inpatient at Cygnet Acer Clinic in Mastin Moor, a facility which specialises in treatment for women suffering with personality disorders.

Assistant Coroner, Susan Evans, said that Leya had been sexually assaulted in her past, had a history of self harm and drug abuse, and had also previously attempted suicide. She had been diagnosed with emotional unstable personality disorder and complex post-traumatic disorder.

The assistant coroner added that Leya had been a patient at a number of health care settings since 2017. She said Leya was detained under the Mental Health Act on a number of occasions, and at the time of her death, was detained under Section 3 of that act.

She passed away after staff found her at 7.31pm on August 12 with a ligature around her neck. Leya survived for six days before treatment was withdrawn, with doctors determining that her brain injury was unsurvivable.

Leya’s death was registered by the assistant coroner as suicide after a jury found that on the balance of probabilities, she had intended to take her own life.

Prior to Leya’s death, she was being observed four times an hour by staff, after she admitted to having taken cocaine whilst on a period of leave from the facility.

On the day she died, however, these observations were decreased to twice an hour.

The jury found that the frequency of the observations at the clinic had no bearing on the overall outcome of her death.

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