In the Nottingham Coroner’s Court
Inquest into the death of Leona Louise McKenzie
Before HM Assistant Coroner Mr Simon Burge, and a jury
27 October – 6 November 2025
The inquest into the death of Leona McKenzie concluded on 6 November 2025 at Nottingham Coroner’s Court, with a jury concluding that Leona had not been appropriately observed by healthcare assistants, who failed to notice signs of physical deterioration, and that there was a 7-minute delay before CPR commenced.
Leona died on 18 October 2024 at Queen’s Medical Centre, Nottingham. Leona had a history of mental health difficulties. Leona was arrested on 12 October after crashing her car and failing to provide a breath sample. Leona informed police that she was attempting to kill herself. She was taken into police custody and then to a place of safety pursuant to police’s powers under section 136 of the Mental Health Act 1983. Leona was admitted to the Farndon Unit, a mental health facility run by Elysium Healthcare, as an informal patient on 14 October.
On the morning of 16 October, Leona presented as distressed and unsettled and a doctor made an order to formally detain Leona under section 5(2) of the Mental Health Act. Leona was placed on Level 3 observations, 1:1 continuous observations, requiring Leona to be within sight of the allocated staff member at all times.
At 12:05pm, Leona fell backwards and hit her head whilst being observed, laying on the floor for approximately 1 minute. The jury found that mental health staff failed to follow the correct procedures and did not report the fall to a nurse as required.
At 12:15pm, Leona was held in a 2-person forearm restraint and administered 1mg of Lorazepam orally. Leona was then recorded to be pacing around, hitting her head, and screaming for a doctor. At 12:41pm, Leona was noted to be asleep.
A nurse went into Leona’s room at 1:15pm and found Leona unresponsive. The jury found that according to CCTV footage of staff movements, CPR did not commence for at least 7 minutes, until 4 members of staff could move Leona from her bed to the floor. Paramedics attended, and Leona was conveyed to hospital. Despite spontaneous circulation being restored, Leona never regained consciousness, and life support was discontinued two days later.
There was a healthcare assistant observing Leona from 12-1pm and another healthcare assistant observing her from 1-2pm. The jury found that these healthcare assistants failed to keep Leona’s whole body within view at all times, despite Leona being on line-of-sight, continuous, observations, and found that the observations were not of the required quality. The jury did find the 15 minute observation recordings were completed.
Evidence was heard at the inquest that these two healthcare assistants have been dismissed by Elysium Healthcare for gross misconduct following concerns about the quality of the observations they carried out, although, the healthcare assistants are appealing the decision.
Leona died from cardiac arrest which led to multiple organ failure. The jury recorded that the underlying cause of the sudden deterioration which led to her death was unascertained.
The Coroner directed the jury that they could not record that any failures in observations or earlier intervention were causative of Leona’s death.
Leona’s family gave evidence to the inquest, describing Leona as having an exciting zest for life and having a massive heart. Leona had previously worked as a care assistant and genuinely cared for the people she supported. The jury recorded that Leona’s mental health deteriorated after the death of her mum in 2023, and Leona had also lost her dad and brother in a car accident when she was young. Her family said that life was never easy for Leona, but she never let go of her smile or her laugh that could light up a room.
Alice Wood of Farleys commented:
“The jury’s findings of failures in Leona’s care are welcomed by the family.
“In inquest after inquest we see similar failings around observations on mental health wards and in this case two healthcare assistants have been dismissed for gross misconduct, and yet the jury were not allowed to consider whether these failings were causative of Leona’s death or at the very least a missed opportunity in preventing her death.
Inquest law requires families to be at the heart of the process, and yet here the family are left feeling frustrated by late disclosure of a large volume vital evidence and being denied sufficient time to process and consider it.
“Interested Persons should be on a level playing field, however, there were a number of instances of late disclosure, including CCTV footage of the unit that was only disclosed on the first day of the inquest hearing, by Elysium Healthcare a private company. This left no time for the family’s legal team to analyse it with the family.
“The Government has recently introduced the Hillsborough Law Bill which will provide vital legal protections for bereaved families, including a duty of candour requiring state agencies to act with candour and disclose information expeditiously. Leona’s family’s experience of the inquest process highlights why this Bill is necessary.”
Leona’s family have made the following statement:
“When we heard Leona was on a life support machine in intensive care in Nottingham, we were driving back from our uncle’s funeral. We headed straight to the hospital and, Leona’s siblings and other family members, sat by her bedside until the end. We have since learnt over the course of the inquest, Leona’s last moments of being able to communicate were spent appearing scared and agitated, without a familiar face close by, and asking for a doctor who wasn’t called.
“We did not know Leona had been admitted to the Farndon Unit two days prior. This was not unusual for Leona, she would normally withdraw consent when she as admitted to hospital, then usually ask to talk to her family and give consent shortly after.
We had, and still have, many questions.
“Only a month before the inquest, we were sent a legal bundle of hundreds of pages. In total for the inquest, there were over a thousand pages of documents to go through in a short amount of time. This was paperwork, statements and policies relevant to the period of time leading up to Leona’s death. Within a few days, we had a Pre-Inquest Review Hearing. We tried to go through the disclosure, but we didn’t have time to process the information. Over the few weeks leading up to the inquest, further evidence was sent through, and more, and more. 50 hours of CCTV was given to our legal team on the Monday morning, when the inquest had already began. It was impossible to feel prepared or even to digest and process all the information.
“We spent 8 days hearing evidence, examining each part of the most vulnerable time of our sister’s life, leading up to her untimely death, whilst an inpatient on the Farndon Unit. We started the process with emotional resilience. Life was difficult for Leona in the end, and things really deteriorated after our mother died in January 2024. We knew that she lived a chaotic life, but we were unaware of the full extent of this, and slowly our resilience became worn. We see this as a small slice of Leona’s life, and we have amazing memories of Leona.
“Whilst we believe there are still unanswered questions and we are very disappointed that lessons haven’t been taken from this, we are eternally grateful to the jury at the inquest. They remained engaged and diligent with their curiosity, focusing on important details when asking questions. We believe the narrative for Leona’s death they wrote is reflective of as much information as the available evidence would allow them, and we appreciate them recognising and documenting the failures in Leona’s care.
We also feel grateful that we had access to a supportive and committed legal team for this process. We became aware that legal aid funded representation for family members has only happened in the past few years. Our hearts go out to all who have had to go through this process without the advice, support and representation that we have been very fortunate to have had.
The family were represented by Alice Wood of Farleys Solicitors and Chris Williams of Garden Court Chambers. The family are supported by INQUEST.
