Autistic Woman Died From Drinking Excessive Water in Mental Health Facility As Carers Failed To Realise It Could Kill Her

The devastated mum of a young autistic woman who died after excessively drinking water says her daughter would still be alive if mental healthcare staff had not neglected her.

Catherine Mitchell, 20, was monitored by two healthcare workers for 24 hours a day at a mental health facility yet nobody stopped her from constantly drinking water, as they did not realise overconsumption could lead to water toxicity and death.

An inquest heard that a catalogue of errors at Springfield University Hospital in Tooting, South West London, including an inability to cater for Catherine’s autism, contributed to her death.

Catherine’s mum Joanne Mitchell, 62, who instructed medical negligence specialists Hodge Jones & Allen to represent her at her daughter’s five-week inquest, called for specialist autism spectrum disorder (ASD) wards at hospitals and training into water toxicity to prevent more deaths.

Joanne, from New Malden, Surrey, said: “Catherine would still be here today if she had received the proper treatment and hadn’t faced blatant negligence that allowed her to self-harm. Staff watching her fell asleep on multiple occasions while they were supposed to be monitoring her around the clock because she was suffering such an acute mental health crisis. This meant she was regularly able to swallow things and harm herself.

“As the coroner pointed out, hospitals, which are loud, bright and full of people, are an unsuitable environment for an autistic woman going through a mental health crisis and this may have contributed to her death. People with autism need a quiet, stable environment away from other people.

“The lack of understanding of how to care for an autistic woman among healthcare professionals is truly shocking and this needs to be addressed along with an ignorance of water toxicity which ultimately killed Catherine.”

Paul Rogers, the coroner at last month’s inquest, indicated he will write a Prevention of Future Deaths report for the Secretary of State for Health, NHS England and the Chief Operating Officer of the NHS regarding the lack of services in the UK for complex adult females with autism and multiple other diagnoses in acute crisis.

The jury concluded that Catherine died ‘as a result of excessive consumption of water whilst under 2:1 supervision’ and the probable cause of death was ‘nursing and medical staff failed to properly assess the risk from water toxicity as a risk of death for Catherine’,

Other possible causes of death listed included the ‘the impact of the unsuitable nature of the acute hospital environment on Catherine’s overall well-being and mental health’, ‘inconsistent training of staff in ASD for those looking after her and the large number of people involved in Catherine’s are with ‘no overarching single mechanism of coordination of that care’.

Catherine had been an inpatient since 20 May 2019 after she started showing signs of psychosis. She also had body dysmorphia and self-harmed. She was transferred to multiple units before she died as no unit felt equipped to deal with her needs.

On 7 and 9 May 2021 staff saw Catherine drinking excessive water but did not mention it to her clinician. Catherine continued to drink excessively in the days leading up to 25 May when she was rushed to St George’s Hospital in Tooting where she died.

Joanne added: “At the inquest I heard for the first time that funding had been previously approved for a specialist ASD nurse to provide 40 hours of care a week for Catherine, but an occupational therapist said she didn’t need it. I am so angry about this. If Catherine had had that kind of care from somebody who understood autism and could have trained staff in how to handle Catherine, then she would still be alive today. Instead, she faced constant neglect and died.”

Nadine Refaat, a specialist medical negligence lawyer from Hodge Jones & Allen who represented Joanne, said: “This is a truly tragic case that saw Catherine failed horrendously on many levels. The lack of understanding of her condition led to a real escalation in her distress, an increase in self-harm and subsequent new behaviours, including the excessive water intake that ultimately led to her death.

“While my client is grateful for the Trust admitting their failings, this will not bring Catherine back. Only a meaningful change in the treatment of people and particularly women with autism, including increasing the number of specialist ASD services, will make a difference.”

Joanne was also supported by charity INQUEST during Catherine’s inquest.