Mum died after 'neglect' on mental health unit

A mother who was experiencing a mental health crisis took her own life following "neglect" on a specialist unit, an inquest into her death has found.

Amy Clare Chapman, 35, died on 27 March 2025 while she was a patient at the Haven Unit at Millview Hospital in Brighton.

Chapman, described by her family as "beautiful, clever and funny", was at her most vulnerable but there was an "absence of basic care" at the unit, according to assistant coroner Nick Armstrong KC.

Sussex Partnership NHS Foundation Trust, which runs Millview Hospital, apologised and said it did "not fully assess Amy's risk or involve her family adequately".

Chapman, who had a two-year-old son, struggled with declining mental health and was admitted to the Royal Sussex County Hospital in Brighton on 3 March 2025.

After being discharged into community-based care, she was deemed to be at high risk of suicide and was admitted to the Haven Unit.

While a patient at Millview, she was allowed out unaccompanied on two separate occasions, and on the second occasion she took her own life.

Chapman's family said they believe her death was "entirely preventable" and welcomed the coroner's findings of neglect.

They also called for change to be made and for those who failed her to be held accountable.

"Amy is so terribly missed and our grief is indescribable," said her family.

"We want those who let her down when she needed them most to be answerable for how they have failed our beloved Amy.

"We also want to see meaningful change, not just words, so this can never happen again."

In his findings, the coroner said Chapman did not receive a proper care plan throughout her time at the Haven and that there was no proper focus or planning as to when and how she might be permitted to leave the unit.

"Amy had not been out before 27 March," he said.

"On that day, however, she was permitted to leave twice and by two different nurses.

"Neither contacted the family, despite the notes suggesting Amy should only go out with family. Neither nurse recorded their decision or the reasons for it in Amy's notes.

"In the circumstances of this case, that was a gross failure of basic care and amounted to neglect."

John Child, chief operating officer at the trust, said: "I offer my sincere condolences to the family of Amy Chapman.

"I am sorry that we did not fully assess Amy's risk or involve her family adequately.

"We have made improvements since Amy's death, including the introduction of a new model of care for patients in our Havens.

While we have done some work to improve the involvement of families and carers, we know there is more to do and we are committed to further improvement in this area."

Madeline Seibert, the family's lawyer at Slater and Gordon, said: "A vibrant, hard-working young mother who had so much to live for was failed by the services that were supposed to protect her.

"We cannot see more families failed in this way."

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