On Monday, Morgan Betchley’s inquest will open in Horsham. Coroner Lisa Milner is sitting with a jury, and Morgan’s inquest is expected to last 10 days.

Morgan was just 19 when she died in March last year, whilst an inpatient at Meadowfield Hospital in Worthing, which is run by Sussex Partnership NHS Foundation Trust.

I caught up with Morgan’s partner, Dominic, his mum Louise and Morgan’s mum Tanya to get to know a little about Morgan and their hopes for the inquest process.

It’s clear from speaking with them that they are trying to find the right balance between public and private. Morgan was shy and private, yet they all feel she would want people to know about what happened to her, especially if it might lead to improvements for others in similar situations.

They have connected with other families via Inquest and seem to have unusually low (but dare I suggest realistic) expectations for the inquest process. Morgan’s mum, Tanya is attending with an open mind to learn what happened:

“I don’t have any big expectations about the inquest, I certainly don’t. I’ll go with an open mind, it’s about accurate truth from our perspective. It’s not about picking on anyone, just the reality of what it is”.

She continues by asking a familiar question for anyone who has read my reporting before, why do things always have to get to crisis point?

“One point I’d like to get across is that early intervention and joined up working is crucial.

We were there ready, willing and wanting to be part of that care, to assist services and that is something that should be non-negotiable”.

When I ask them what they’d like the world to know about Morgan, Dominic thinks for a moment before responding:

“She was a very motivated, a very, very motivated mother. That’s completely indisputable. She always gave 100% to me and our son. She was a very, very good partner as well, especially for someone her age. Very mature”.

Morgan and Dominic met when she changed schools at the beginning of Year 10. They became friends at school before starting a relationship. A couple years later they discovered Morgan was pregnant and their son was born in mid 2021.

Louise, who is a senior midwife, sings Morgan’s praises as a mother. Morgan breast fed her son for a long time and was always keen to cook for him, with what she refers to as homely cooking.

“She really was very, very good… to the point now he’ll eat anything. He will eat salmon…. she did baby led weaning… she was tolerant, gave him proper healthy food, not rubbish”.

The conversation sticks on the topic of food. Tanya, Morgan’s mum, describes how her own mother had made her tandoori chicken, and she in turn would make it for Morgan, that was their family dish of the month, a firm favourite.

Morgan also liked a Victoria Sponge cake. Dominic agrees, adding Morgan loved her birthday cakes and icing in particular. At this point I can feel my teeth starting to itch, I’ve never been an icing fan, but Tanya tells me Morgan would eat chunks of the stuff if she could. Dominic laughs before sharing Morgan would go to the shops and eat a whole pack of fondant icing, if the mood took her.

Morgan’s favourite colour was baby pink, all her favourite clothes were that colour. Like mother, like daughter, Tanya is wearing a baby pink cardigan on this call.

Dominic tells me that Morgan got on with adults a lot more than people her own age:

“She may have struggled at times, she did have some friendship problems and stuff going through school, nothing to do with the person she was, she just got on better with people older with life experience”.

He points out that Morgan was a mum, and had a job, at a much younger age than most people do. Tanya thinks that it was also related to Morgan’s autism. She flags that Morgan could misunderstand people’s reactions and sometimes misread people. She explains a little more before realising that she is describing rejection sensitivity and Dominic agrees:

“She did give her all for everything. She was a budding artist too, very talented, but she didn’t like to show it off. They were really good pieces, I would find them when cleaning the house or something, had never seen them before. An amazing drawing… did freehand, in a day, she used to keep a lot of things private, even big achievements, she would never show things off but she was actually very proud of it”.

Dominic returns once more to Morgan being a private person, and that someone looking from the outside might think she was introverted and shy. Which he says, she could be, but with people that Morgan really knew she was extroverted, and fun, and kind.

Louise reflects that Dominic and Morgan were a very stable couple. She describes them being very young parents, going through birth, and covid, and A Levels and Morgan being in a mother and baby unit, and despite all those pressures, they had a really loving kind relationship “with no drama or trauma”. She reflects that this is completely at odds with the label of Emotionally Unstable Personality Disorder that Morgan was given:

“The diagnosis of EUPD is often given to women who are deemed to be hormonal, or hysterical, or considered to be constantly up and down or attention seeking. If that were the case Morgan and Dominic hardly ever had an argument … they went through all that and ostensibly had a really loving kind relationship with no drama or trauma. They wouldn’t have been able to do that if Morgan had an inherently unstable personality disorder”.

Dominic says he and Morgan were both very tolerant and appreciated what they had.

“We were both very tolerant, it is what it is sort of attitude. Got on with things, even when they were really tough. We appreciated what we had.

Looking at brighter things, small things, times out with our son. We couldn’t afford to do massive things or holiday abroad, but we enjoyed feeding the ducks. We had a great holiday on the Isle of Wight, small little things.

Morgan was very simple as well, she didn’t need big holidays or material things, prams or anything, she was happy living a simple life where she got on with things really”.

Tanya had popped out for a short while and returns to this comment from Dominic. She agrees with him, saying Morgan was very giving, she was a really caring girl and wherever possible she would always want to do thoughtful things for people. She was also really bright and really funny with a dry sense of humour and a skill for a one liner.

As a teenager Morgan was a member of the Army Cadets, she went camping and took part in community projects. She enjoyed interior design, art and writing. Tanya remembers that Morgan would often make and send small decorated cards to people, either as a thank you or simply to express herself and share what she was thinking.

It was also as a teenager that Morgan’s mental health declined. I’ll not detail it here, because it’s not the focus of getting to know Morgan. I will say Morgan and her family clearly advocated strongly for her to get the support she needed, including agreeing for Morgan to become a looked after child at 16, in a desperate attempt to get her help.

The year before a social worker had suggested to 15 year old Morgan, and Tanya, that she might be autistic and she was added to a CAMHS waiting list for an autism assessment. Morgan waited three years for an autism assessment, receiving her diagnosis shortly after her 19^th birthday.

Having waited years for the diagnosis, Tanya recalls there was no targeted help or support then offered. She also feels there was no autism appropriate care or reasonable adjustments made for Morgan when she was admitted as an inpatient.

It is clear Morgan is much missed by all of them, and they all have questions that they’re seeking answers to. 

I ask them what they are hoping for from the inquest process. The common theme across their responses is a desire to understand why what happened, did.

Dominic is hoping one of Morgan’s clinicians will explain what he calls a “catastrophe of diagnoses” and their reasoning for saying they did not believe Morgan was autistic.

Tanya wants to know why certain clinical decisions were made, why risk assessments and observations were changed so close to Morgan’s death. She says the last thing Morgan wanted was strangers around her, that it would be excruciating being watched as a private person, but she wanted help and she believes that Morgan was failed.

“She was hugely failed in that respect. It could have been so much better if they’d worked alongside us, listened to us and communicated. We could be in a very different place now”.

They mention other key staff members who they wish to hear account for themselves and their actions.

In the months leading up to Morgan’s death, her mental health deteriorated. In the six weeks before she died, she had a number of admissions to A&E following suicide attempts, and was admitted to Meadowfield Hospital on three occasions.  
 
During her second admission to the hospital at the end of February 2023, Morgan was arrested after she was found having ligatured. She remained in police custody for 24 hours after which she was again detained under the Mental Health Act and transferred back to A&E.
 
Morgan was eventually taken back to Meadowfield Hospital as a voluntary patient on 3 March. Six days later staff found Morgan ligatured in her bedroom. She was pronounced dead soon after.
 
The inquest will examine the events leading up to Morgan’s death, including the care and treatment provided by the mental health services from January 2023 onwards.

Morgan’s family are represented by Charlotte Haworth Hird of Bhatt Murphy, who has instructed Jess Elliott of 1 Crown Office Row. Dominic, Tanya and Louise all agree the whole inquest process has been made much easier by their legal team. They have confidence in them and add that they are grateful that they are representing Morgan.

Morgan’s inquest starts on Monday. I’ll be reporting the first two days and hope to return for the conclusion.