Re: Sam Pounsberry

Marcus Coates-Walker

28 September 2021

Marcus Coates-Walker was instructed by Royds Withy King to represent the family in an inquest into the death of a woman who ended her life while detained as an inpatient on a mental health ward in Devon. The Coroner heard from over 30 witnesses across 7 days of evidence, and it was concluded that there were numerous failings in her care.

The jury found that the staff at Moorland View Hospital did not appreciate the risk that Sam Pounsberry posed to herself of self-harm or suicide and did not put in place adequate measures to control these risks. There were “failures to follow policies and procedures in place regarding risk assessments, observations and patient care plan throughout Sam’s admission”. In addition, they found that there was a “failure of senior management to monitor and oversee staff adequately”, there was “inadequate staff training” and “erratic and inconsistent recording of Sam’s observations and observation levels and a lack of accountability regarding changes made”.

View media here.