A coroner’s inquest reveals failures in care led to the tragic drowning of an 18-year-old in a mental health unit
Walker: It’s such a heartbreaking story. An 18-year-old girl named Codie Lee Black tragically drowned in a bath while she was in a mental health unit. The coroner found that a series of failures in her care contributed to this awful incident.
Codie passed away at the Carleton Clinic in Carlisle on January 31, 2023. She was a talented young woman who loved art but had been struggling with mental health issues for years, stemming from abuse she suffered when she was just 13.
The coroner, Margaret Taylor, ruled that Codie was allowed to take a bath unsupervised, even after she had mentioned researching drowning. It’s just so shocking. There were clear failings in the NHS care she received, including an inexperienced staff member who didn’t properly assess the risks.
The clinic is run by the Cumbria, Northumberland, Tyne and Wear NHS Trust. The coroner pointed out that the staff member didn’t check on Codie while she was in the bath, and when they didn’t hear back from her, they didn’t even go in to check or raise an alarm.
It gets worse. The nurse in charge approved Codie’s bath request without asking about her mental state or giving proper instructions to the junior staff. Codie had been through so much, and it feels like the system let her down.
Her mom, Helen, shared how talented Codie was and how she had even won a national award for her artwork. It’s heartbreaking to think about all the potential lost. Helen expressed disappointment with the verdict, especially since there was no finding of neglect, but she’s determined to fight for justice for her daughter.
Codie had been diagnosed with emotional instability and PTSD due to her past trauma. She had numerous hospital admissions and was in a tough transition to adult services. Sadly, she disengaged from mental health support, which led to her tragic end.
The coroner noted that Codie’s behavior had become increasingly unstable while at the clinic. On the day of her death, an inexperienced healthcare assistant was supposed to keep an eye on her but failed to do so properly.
Dr. Rajesh Nadkarni from the NHS Trust expressed condolences to Codie’s family and promised to reflect on the coroner’s findings to improve their services. It’s a tough time for everyone involved, and hopefully, lessons will be learned to prevent this from happening again.
