A shocking series of failures contributed to the death of a Walker teenager who drowned in the bath on a mental health unit, a coroner has found.
Codie Lee Black, 18, died at the Carleton Clinic in Carlisle on 31 January 2023. Codie – a bright young woman who loved art and “showed real talent” – had been through years of mental health difficulties which followed sexual abuse she experienced at just 13.
Margaret Taylor, assistant coroner in Cumbria, ruled following an inquest in December that Codie’s had been allowed to have a bath unsupervised despite the fact she had previously disclosed that she had researched drowning. The coroner recorded a verdict of “death by misadventure” but found a series of NHS failings had contributed to her death – including that an “inexperienced healthcare assistant” had not “adequately risk assessed” Codie’s request to have a bath.
The clinic is operated by the Cumbria, Northumberland, Tyne and Wear NHS Trust (CNTW). Assistant Coroner Taylor also highlighted that the member of staff breached CNTW policy by not “visually checking” on Codie while she was in the bath. Then, when they received no response to a verbal check, the staff member failed to enter the bathroom or activate an alarm.
Meanwhile, the coroner highlighted how nurse in charge agreed to the request for a bath without “making any inquiry” about Codie’s mental state and without providing instruction to the more junior member of staff about how to keep Codie safe.
Codie Lee Black, who died in January 2023
(Image: Family handout)
The CNTW NHS trust has said it will “reflect” on the issues highlighted by the coroner and use lessons learned to improve services.
Codie, who had previously been a pupil at Benfield School in Walkergate, struggled with post-traumatic stress disorder and emotionally unstable personality disorder following the abuse, at the hands of a friend’s relative, she experienced as a youngster.
Her mum Helen said Codie had “excelled at all she did” and was talented and caring. She told of how Codie had won a national award for her artwork. “She had so much going for her, she was so talented.” She said her family had been disappointed at aspects of the verdict – there was no finding of neglect – but would continue to fight for justice.
Helen added: “I’m fighting for justice for her, it’s the least we can think to do for her. Codie was taken to Carlisle as there were no beds in Newcastle and she wasn’t there a week. There were such massive failings.”
In their ruling on Codie’s death, Assistant Coroner Taylor wrote: “She had been diagnosed with an emotional unstable personality disorder and post traumatic stress disorder attributed to trauma suffered as a consequence of sexual abuse perpetrated upon her by an older man when she was thirteen years of age.
“She began to self harm and was referred to children’s mental health services. There followed numerous admissions to hospital many of which were under the authority of the Mental Health Act. As Codie approached the age of eighteen arrangements commenced to transfer her care to adult services.
“Transition proved challenging and Codie chose to disengage with mental health services which led to her discharge on 22 May 2023. Her period of relative stability was short lived and there followed a period of prolific self harm and admissions to hospital. Following several overdoses in short succession she was admitted to the Royal Victoria Infirmary and from there transferred to the Carleton clinic.”
The coroner said that they had heard how Codie’s behaviour became “increasingly dysregulated” while she was on the ward there. They added: “On 31 January an inexperienced healthcare assistant was allocated the responsibility of conducting ten minute observations upon Codie. Shortly after 1pm Codie requested to use the bathroom to have a bath. Despite disclosing that she had researched drowning there was a failure to adequately risk assess this activity.
“The health care assistant sought authority from the nurse in charge who agreed the request without making any inquiry about her mental state or providing instruction to the junior member of staff about how Codie’s safety could be maintained.”
Assistant Coroner Taylor added: “death. There was a failure by the health care assistant to visually check upon Codie whilst she was in the bath as required by the Trust’s observation and engagement policy.”
The coroner found these failings “more than minimally contributed to Codie’s death”.
Dr Rajesh Nadkarni, executive medical director at Cumbria, Northumberland, Tyne and Wear NHS Trust, said: “Our thoughts are with Ms Black’s family and friends at this very difficult time. We will reflect on the conclusions drawn by the coroner. We will make sure that this happens in a timely manner and the lessons learnt will be used to improve our services.”
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