The mother of a young woman who took her own life after being neglected by a mental health nurse has urged that lessons be learnt from her death. Amy Barber had a history of self-harm and was supposed to be checked on every five minutes inside a specialist psychiatric care unit on the Clatterbridge Hospital complex. But 54-year-old mental health nurse Laurence Tchapong did not perform an observation for nearly 25 minutes. By the time one of Tchapong's colleagues entered Ms Barber's room at the Brooklands psychiatric intensive care unit, the 22-year-old was unresponsive on her bathroom floor.
Nurse 'deliberately lied' in observation notes
A Liverpool Crown Court trial heard Tchapong "deliberately lied" in her observation notes "to try and evade justice". It emerged that the mental health nurse could have "callously disregarded" Ms Barber because she bore a "grudge" after the young patient reported her to management for falling asleep on shift. Instead of accepting blame, Tchapong was "resentful" towards the hospital and believed she was a "scapegoat". The mum-of-one was jailed this week for four years after a jury convicted her of wilful neglect of a patient. The judge found her to be unremorseful for her actions.
Ms Barber's mum Susan told court that her daughter was "the most caring, bright and intelligent girl I've ever met". Reading her moving victim statement from courtroom 46, she said her daughter was "driven", but had a complex mental health history, first presenting to services in November 2014 when she was 14. She was diagnosed with emotionally unstable personality disorder and an eating disorder. However, despite her challenges, she gained 11 A*s in her GCSEs and wanted to go to Oxford. Her mum said she had aspirations of working as a barrister after the pair visited the United Nations headquarters together. She even carried the Olympic torch in 2012 because of her work helping others.
Timeline of events leading to death
Susan Barber said she phoned the crisis team in May 2018 because her daughter planned to end her life. Ms Barber, still a teenager at the time, was taken to A&E and "never came back out of hospital", her mum said. She spent time in a unit in Leeds where she had her only psychiatric engagement. "After this point she was medicated and contained," the mum said. Ms Barber was taken to the Brooklands ward in November 2021 with the plan to get her stable. The move brought her closer to her home in Nantwich, her family, friends and dog Daisy.
But Ms Barber was still extremely unwell and was put on observations which meant a nurse had to always be within "arm's reach". Her mum told the court this week that when asked how the unit would notify her if her daughter took her own life, the response was "it won't happen on our watch, we are too good at what we do". By the end of June 2022, Ms Barber had not engaged in serious self-harming behaviours for a number of weeks and her observation was dropped to level 2. Level 2 observation can vary, but it was agreed Ms Barber would be checked on every five minutes and have access to bathroom privacy.
Susan Barber said on June 30 she spoke to her daughter at 7.50pm about plans the pair of them had made for the upcoming Sunday. She told the court they were going shopping, with lunch at Nando's and a coffee at Costa. "It was the first time the two of us would be off a hospital site in three years," she said. "I bought a dress especially for this. It would have been my Amy and me." The mum said she instead wore the dress to the funeral.
CCTV contradicted nurse's records
Tchapong had responsibility for level 2 observations between 8pm and 9pm on the same night. Records from that night showed the nurse had indicated she had carried out the five minute checks, however the ward's CCTV told a completely different story. "The footage reveals that at least 10 entries signed by Laurence Tchapong, indicating she had observed Amy Barber awake, did not actually occur," prosecutor Katy Appleton said. Ms Barber was last seen alive and well at 8.15pm when Tchapong handed her a towel.
Registered nurse Victoria Connelly, who was on medication duty that night, found Ms Barber at 8.40pm. A 999 call was made for an emergency ambulance to attend and Ms Barber was taken to Arrowe Park Hospital. Ms Barber's mum told the court that she felt numb when she got the call. "I knew she was dead, I told my partner not to rush because I knew," she said. Ms Barber was pronounced dead at the hospital on July 4.
Susan Barber told the court this week that her daughter did not want to die. "The worst time of day for Amy was between 6 and 9 at night," she said. "This was when she was most anxious and in need of support." She said her daughter struggled to ask for help so self-harmed to show if things were not okay. Tchapong told her superior, senior psychiatrist and clinical lead Gill Judson, that Ms Barber had asked for an apple at 8.40pm and a towel five minutes later. Tchapong had also recorded an "A", for "attended", or a "question mark" at 8.55pm - the time when staff were carrying out CPR on Ms Barber.
Family's plea and trust response
Susan Barber said her daughter "burnt incredibly bright for such a short time," adding: "I'm proud of being her mum. She made it so easy for me." But the mum said her daughter's drive had been "taken away by a system that let her down," telling the court: "Please learn from this." Gary Flockhart, director of nursing, therapies and patient partnership at Cheshire and Wirral Partnership NHS Foundation Trust (CWP), which operates Brooklands, told the ECHO: "On behalf of everyone at CWP, I offer our deepest and most heartfelt condolences to Amy's family and friends for their devastating loss. We are shocked and extremely saddened that this crime happened at our hospital. Our priority is, and always will be, the safety, dignity and wellbeing of those in our care. We expect all colleagues, including agency staff, to uphold the highest standards of compassionate care for our patients, and we remain committed to learning and making meaningful improvements."
One of the most worrying pieces of evidence heard during the trial was that Tchapong was working two jobs at the time of the incident. Tchapong, of Penroyson Close in Manchester, was working full-time at Cromwell House, a community mental health team in Salford, as well as at Brooklands. Deployed to Clatterbridge Hospital through agency iCare24, Tchapong was working five 12-and-a-half hour night shifts a week, usually at the Brooklands ward. The court heard her Manchester job rota had not been made available for the week of the incident, so it was not possible to determine what impact it had, but it was likely that she could have been working a 100-hour week.
The ECHO approached the Greater Manchester Mental Health NHS Foundation Trust and asked if it knew Tchapong was also working agency shifts and, if so, was it communicated with Brooklands. However, we received no response. The ECHO also approached iCare24 for comment but received no response. The result was Tchapong had fallen asleep on shift at Brooklands twice - once in January 2022 and again on June 23, just a week before Ms Barber was found unresponsive. On both occasions Ms Barber sent a picture of the sleeping nurse to her mum. One time she told her mum "got feeling she won't be returning when I present this image".
Judge Anil Murray, presiding, said: "Why the defendant callously disregarded Amy we will never know unless she reveals that...[but] I'm sure the defendant held a grudge towards Amy for a perceived lack of warmth towards the defendant and because Amy had previously complained about the defendant." Tchapong, who moved to the UK from Cameroon on a student visa, was a 20-year veteran of mental health nursing after gaining her qualification in 2004. Patrick Cassidy, representing Tchapong, said: "She recognises now that there is no future for her in nursing." Mr Cassidy added: "Everyone connected to the deceased has suffered in the years since. It may be difficult for the family, but it is also the case that the defendant, whatever denial about her role, has also suffered as her health has declined and her anxiety and depression has taken hold of her."
Judge Murray said it was clear Ms Barber had a history of self-harm but attempts had been unsuccessful because life-saving efforts had been made by staff who had followed the rules and carried out observations as they should. Judge Murray said: "The defendant has not been charged with causing the death of Amy, but the clear evidence is that Amy's death was preventable if the observations had been carried out." Speaking after sentencing, Merseyside Police Detective Inspector Emma Kerrigan said: "Tchapong completely abused her position of care for Amy...[she] then lied to her managers about what happened that night and put Amy's family through the added trauma of a trial. Thankfully the jury saw through her lies and she was jailed for her complete lack of care, neglect and compassion." Senior crown prosecutor Maqsood Khan added: "This was a young woman receiving treatment in an environment where she and her family had every right to expect she would be properly cared for and safeguarded. The impact on her family has been profound, and our thoughts remain with them."
