Inquest Concludes into Death of India Walker at Elmleigh Hospital: inadequate response by hospital staff to patient who fatally self-harmed

India’s Life and Mental Health Struggles

Described by her family as a “precious daughter, granddaughter, and sister, who was kind, generous, and creative,” India had spent much of her teenage years making care packages for the homeless and building a global network of pen-pals.

India’s mental health began to deteriorate after she started university, and she was hospitalised in Gloucestershire for almost a year before being discharged into the community. During this time, a comprehensive risk management plan had been put in place, including 1:1 observations and a ligature risk plan.

Whilst she had been provisionally diagnosed with Emotionally Unstable Personality Disorder (EUPD) - a psychiatric condition which is contested and is primarily made in respect of young women - India’s diagnosis was unclear owing to difficulties diagnosing young people under 25 years of age.

Failures in Care at Elmleigh Hospital

Throughout the two-week inquest at Winchester Coroner’s Court in October 2024, the jury heard that India was admitted to Elmleigh Hospital on 28 September 2021, following a decline in her mental health and multiple self-harm attempts.

She did not improve during her two-week stay, continuing to report suicidal ideation and frequently self-harming, but despite this, evidence was heard that her risk management plan and crisis plan created on admission were not updated or changed, her observations were never increased, and her room was never searched.

A craft knife blade was found hidden in her phone case after her death.

Claire Macmaster, a specialist inquest lawyer from Simpson Millar who supported India’s mother throughout the hearing, said this was ‘particularly concerning’ in light of  someone displaying symptoms of EUPD, which can result in severe mood changes and unpredictable behaviour, making it difficult to assess and manage risk unless patterns of self-harm incidents are documented and noticed by staff.

Further, expert witness Dr Chess Denman, Consultant Psychiatrist, who initially deemed India’s care “adequate” later revised this following questions from the maternal family’s counsel, to “less than adequate” after questions about her previous risk management.

She testified that had she been aware of India’s former 1:1 observation levels, she would have applied similar restrictions. She also suggested that transferring India to a specialist unit for more holistic care might have been considered if the risk had not decreased.

Whilst multiple concerns came to light with regards India’s care throughout her two week stay, at the conclusion of the inquest the jury focused on multiple failures on the day of India’s fatal self-harm that possibly contributed to her death. To included:

• Observation Delay: India’s 15-minute check, due at 23:00, was not conducted until 23:09, when she was discovered.
• Inadequate Handover: Issues with the handover led to the delay.
• Emergency Delay: The 999 call was placed seven minutes after she was found.
• Insufficient CPR: Over 96% of chest compressions were too shallow.

The Coroner will hear evidence in relation to Prevention of Future Death matters at a later date.

Family’s Reflections and Call for Change

Claire Macmaster of Simpson Millar, who supported Victoria and India’s step-father throughout the inquest, said: "This inquest has raised important questions about the standard of care provided to young women with a potential diagnosis of EUPD in acute mental health settings. There is a need for a discussion within the mental health profession as to whether acute psychiatry wards are suitable for patients with EUPD who present with deliberate self-harm which does not reduce following admission.

“Acute wards are trained at managing short term mental health crisis, often with medication. The evidence heard at the inquest from the expert witness indicated that in some cases a more specialist environment may be needed for patients with EUPD, particularly where a short term acute stay does not reduce incidents of deliberate self-harm or even causes risk to escalate.”

Speaking after the inquest, Victoria, India’s mother and Stepfather Jukka said that they were grateful to have had a thorough investigation into India’s death. However, it was only through the inquest process that they were able to learn the facts surrounding India’s tragic passing, in part due to the silence they received from the Trust when they tried to get answers about India’s death.

They were devastated to learn of the multiple failings that possibly contributed to their daughter’s death, all of which they consider were avoidable.

Victoria and Jukka said: “Although we are grateful to the coroner and jury for their work, we are disappointed that the negative impact of social media on India was not picked up by the jury. We believe that India’s unfettered access to social media whilst in hospital greatly hindered her chances of effective recovery.  

“We were also horrified to learn that staff also joined in making videos with patients whilst on the ward, which was grossly unprofessional in our opinion. India received some exceptionally vile, hateful messages to her social media posts, and we believe this must have negatively impacted her.

“It is now common knowledge how harmful the effects of social media can be, and for this to not be taken seriously by the very people who were meant to keep her safe, is a horrifying thought.”

Remembering India Walker

Victoria and Jukka added: "India had a future full of plans and dreams—she wanted to travel, expand her small businesses, and stay connected with her wide network of friends across the world. But now, there will forever be an empty seat at our table, and a silence where her laughter and music once were. Our lives will never be the same without her."

India was known for her charitable nature, her beautiful artwork and photography that depicted the natural world, and her zest for travel and exploring new things. Her mother reflected on the enormous gap India’s passing has left in their lives: "India was precious to us as a daughter, granddaughter, sister, and friend. She was irreplaceable, and the world has lost a truly beautiful soul.

“She was more than a diagnosis, a patient or a TikTok handle – she was our little girl – our Indie - who had so much to give to the world.  Although she only had 20 years with us, she lived a life of adventure and leaves us with so many wonderful memories of her throughout her childhood.  A light gone too soon. "

Claire Macmaster and Bernadette Barrett represented India’s mother at the inquest, and counsel was  Matthew Turner of Doughty Street Chambers.

The Coroner was HM Senior Coroner for Hampshire, Mr Christopher Wilkinson. The other Interested Persons were the paternal family and Southern Health NHS Foundation Trust.