Farleys Solicitors acted on behalf of the mother of Rianna, who died at the age of 20 on January 6, 2025, after a self-harm incident at Sherwood Oaks Hospital in Mansfield where she was a patient.
The 7 day Article 2 inquest commenced on 15th June 2026 and heard evidence from a number of professional witnesses involved in her care including mental health nurses and treating psychiatrists and psychologists.
The Facts
The jury heard that Rianna had a diagnosis of Emotionally Unstable Personality Disorder (EUPD) and Attention Deficit Hyperactivity Disorder (ADHD). She had a complex history of self-harm and as a result of a deterioration in her mental health she was admitted to Sherwood Oaks under the Mental Health Act in July 2024.
Rianna was described by her mother as being very academically talented from a young age. At the age of 3 years she started to play the piano and she excelled in a number of extra curricular activities such as tennis, Skiing and arts. Rianna went on to secure a place at Nottingham University to study for her degree.
On 4th January 2025 Rianna was discovered during hourly observation checks lying on the bathroom floor of her bedroom with a ligature around her neck. The inquest heard that Rianna had used a towel, which she later used to harm herself, for its intended purpose a few hours earlier, but that there was no set practice on the ward for the returning of such items, nor was it officially recorded when they were provided.
CPR was commenced and Rianna was transferred to hospital. It was tragically determined that she had suffered irreversible hypoxic brain injury and the decision was made to withdraw treatment. Rianna died on 6th January 2025. The jury found that Rianna, at the moment of her final act, did not have the capacity to form the intention to take her own life, therefore did not have the intention to do so.
At the time of her death Rianna was on general observations and at the time of the incident she was detained under Section 3 of the Mental Health Act. A decision was made to rescind the Section 3 on 5th January 2025 which meant Rianna remained at the hospital as a voluntary patient. During the proceedings, questions were asked of professionals about why Rianna was only being observed once every hour at the time of her death – a pattern of observations usually reserved for patients who present ‘no significant risk’. This was despite Rianna self-harming 23 times in the previous 23 days before the fatal incident. Self-harm attempts were so serious during this period that Rianna required oxygen to resuscitate her.
Rianna had been on more regular observations – once every fifteen minutes – but was downgraded from these to hourly observations just days before the fatal incident.
On day 1 of the inquest, the consultant psychiatrist heavily involved in Rianna’s care admitted that staff should have reassessed the risk of her having access to materials that she used to kill herself. Rianna was using the same materials in her bedroom each time she self-harmed.
Conclusion
Having heard all of the evidence, the Jury concluded that:-
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the regime of hourly observations then enforced by the facility was not appropriate, due to Rianna being put on section 3 three days earlier and the increased occurrence of self-ligation over the previous days.
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The low level of observations significantly contributed to Rianna’s death.
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Allowing unsupervised access to towels contributed in part to her continuous self-ligating incidents and contributed to her death. The jury found that the level of supervision and control of towel access in the facility was not adequate, given her history of incidents involving said objects as a preferred method of self-ligature.
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There were multiple opportunities to prevent Rianna’s death, including but not limited to, increased observations, a change to the protocol governing access to towels or a change to the towels themselves.
An inadequate observation and control regime in place at Sherwood Oaks at the relevant time, coupled with a failure to properly monitor and supervise the provision of towels more than minimally contributed to Rianna Poiana-Lazarec’s death by self-ligating with a towel.
Assistant Coroner Simon Burge issued a Regulation 28 report to NHS England concerning the use household items in mental health detention which pose a clear risk and is of the view steps should be taken to mitigate future deaths.
The case was featured in national and local press.
Carl Buckley of 33 Bedford Row was instructed by Kelly Darlington, and assisted by Natalie Tolley, of Farleys Solicitors.
Rianna was the third young patient with EUPD to die at facility run by Nottinghamshire Healthcare NHS Foundation Trust in just four years, after Louise Furlong in September 2022 and Sophie Towle in May 2024. Farleys Solicitors represented Sophie’s family in the inquest into her death which the Jury found was contributed to by neglect.
