The jury returned to court at 16:21. They gave their findings and conclusion but when the coroner went to sign the form she realised in Box 3 they had referred to ‘the deceased’ and not Morgan’s name. She explained that for legal purposes that would have to be corrected.

Court was then adjourned again whilst the jury returned to their room to complete a new record of inquest and they returned to court at 16:41 to give their conclusions again.

C: Would the foreman please stand. Members of the jury have you reached findings and a conclusion upon which you are agreed?

Jury foreman: Yes

C: Have you entered those findings and your conclusion on the Record of Inquest, and have you all signed them?

Jury foreman: Yes

C: What are your findings in Section 1

The jury foreman read them, I’ll not report as they include personal information such as Morgan’s address.

C: Thank you, Section 2?

Jury foreman: Medical cause of death hanging

C: Thank you, Section 3?

Jury foreman: Between 3:15am and 3:30am on 9 March 2023 Morgan Rose Betchley… hanged herself from her bedroom door on Rowan Ward (see Section 4) Meadowfield Hospital, Arundel Road, Worthing, West Sussex.

The coroner then asked him to read the particulars in Section 5, which again I won’t report.

C: What is your conclusion in Section 4?

Jury foreman: Morgan died as a result of her own actions. Historical evidence suggests that in all probability Morgan’s intent had been to self-harm as a cry for help and that it was not her intention to end her life.

Morgan was a young vulnerable adult who had suffered with her mental health for many years, including a history of self-harm and suicidal ideations.

Following a significant decline in her mental health she was admitted and sectioned under Section 2 and Section 136 on multiple occasions to several medical facilities, for her safety and to receive an enhanced level of care.

The evidence shows repeated failures to follow policies and procedures by the staff at Meadowfield Hospital. Failures relating to:

• Admission processes
• Understanding existing diagnoses
• Risk management
• Record keeping
• Family involvement
• Discharge planning

prevented Morgan from receiving access to services she needed at the time.

We consider it probable that if policies and procedures had been followed Morgan would have benefitted from a level of care more closely aligned to her complex needs, including her diagnosis of autism.

In the days running up to Morgan’s death, there was a failure to act professionally by some members of hospital staff.

Following an earlier incident of assault, the deceased’s attempts to apologise were not handled in a professional manner by senior staff members of Rowan Ward, leading to a fractured therapeutic relationship.

Whilst nursing staff did not actively exclude Morgan from receiving care, the situation was made unnecessarily stressful for Morgan.

The evidence of the court focused on the frequency of observations on the night of Morgan’s death. However, whilst it’s possible that more frequent observations may have helped to better understand her level of risk, we feel it more probable that better quality observations and interactions would have led to a greater understanding of Morgan’s state of mind.

C: Thank you, I shall now sign the record as the coroner. Thank you very much jury for your service over the last two weeks, your attention and your patience and your hard work.

The jury service continues to play a significant part of the inquest process and jurors therefore play an important public role.

In longer inquests such as this one it takes a lot of time and dedication, taking you away from work and other duties… sometimes sacrifices on your behalf.

Thank you very much for the service you have played in this inquest

JE: Ma’am, may I ask that the thanks of the family are passed to the jury for their hard work over the past two weeks.

C: Thank you. I’d also like to thank the family for their hard work, and assisting with the prevention of future deaths… I appreciate very difficult process … but assisting me in prevention of future deaths.

Also like to give my thanks to Ms Elliott and Ms Agnew [Mr Berlevy had to leave before the jury returned for a second time]. Thank you very much for your assistance.

I’d like to pass on my severe condolences to the family.

That concludes the investigation and the inquest touching on the death of Morgan Rose Betchley. Thank you.

Morgan’s inquest finished at 16:48 on Friday 22 November.