Neglect from mental health service led to young mother’s death

Amy Clare Chapman, 35, died on March 27, 2025, after jumping from a bridge on the A27 north of Hove. She was a patient at the Haven Unit at Millview Hospital in Brighton at the time, and was allowed out unaccompanied when she died, which was against the knowledge and wishes of her family.

Her devastated family, who have described Amy as “beautiful, clever and funny”, say 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 Amy to be held accountable.

“We firmly believe that if Amy had received the care she needed and deserved, she would still be with us today,” her family said. “During Amy’s mental health crisis, which lasted approximately three weeks, our family found ourselves overwhelmed and unprepared. With no prior experience of mental health services, we trusted that Amy’s best interests would be at the centre of her care. Tragically, she was let down, and this failure cost her life.

“Amy is so terribly missed and our grief is indescribable. 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.”

Amy, mother to a then two-year-old son, was a dental hygienist and Newcastle University graduate. She had struggled with declining mental health and was admitted to the Royal Sussex County Hospital on March 3. After being discharged into community-based care, Amy was deemed to be at high risk of suicide, and she was admitted to the Haven Unit.

However, the inquest into her death at Hove Coroner’s Court found a series of failings from the unit, managed by Sussex Partnership NHS Foundation Trust, and an “absence of basic care” for Amy at her most vulnerable. This included poor record keeping and the lack of any kind of care plan for her.

Despite never being allowed out unaccompanied, Amy was allowed out twice on March 27 – the second being the time she took her own life, diverting her frantic partner to another location when he tried to track her down.

In his findings, Assistant Coroner Nick Armstrong KC said: “Amy did not receive a proper care plan throughout her time at the Haven, and in particular 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 March 27. On that day, however, she was permitted to leave twice and by two different nurses. Neither nurse knew Amy well. Yet neither checked her case records before agreeing that she could go. 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.”

Amy’s family said they are grateful for the Coroner’s findings, echoing that they believe Amy was failed in multiple ways.

“We placed our trust in mental health services to care for and protect her, but instead encountered serious shortcomings,” they said.

“These included failures in the management and administration of her medication, poor record-keeping, and inadequate communication. As a family, we were kept in the dark and were unable to advocate effectively for her. There was also insufficient monitoring of Amy, which ultimately led to her death.

“We are desperate that lessons are learnt from this, and that by us speaking out about the poor care Amy received, this can help change things for other families, so they do not have to live with the daily devastation that we face.”

Amy’s family are being supported in taking action against Sussex Partnership NHS Foundation Trust by law firm Slater and Gordon.

“ At a point in Amy’s life where she desperately needed the treatment, care and support of mental health services, tragically she was let down,” says Madeline Seibert, principal lawyer who is acting for the family.

“A vibrant, hardworking young mother who had so much to live for was failed by the services that were supposed to protect her – and the impact of her loss on her family has been utterly devastating. We hear so many times that lessons must be learned, but action as a result of Amy’s death is absolutely essential. We cannot see more families failed in this way.”