Rachael Gourley represents family of 16-year-old Elise Sebastian who died following neglect and gross failures in her mental health care
20th June 2025
Rachael Gourley, instructed by Amanda Smith and Nina Ali of Hodge, Jones and Allen, represented the bereaved family of Elise Sebastian at the Article 2 jury inquest into her death.
Elise, a vulnerable 16-year-old with autism, died after tying a ligature around her neck on 17 April 2021 whilst a patient under the Mental Health Act 1983 at St Aubyn’s Centre in Essex.
The jury found that Elise’s death could have been prevented or her life prolonged if not for multiple failings in her care, stating that there were two main factors as follows:
(a) “poorly administered observations due to poor staffing levels and falsified information in observation forms”; and
(b) “Elise being able to gain access to her room and her observation level in an isolated area not being considered”.
Finding that these factors led directly to Elise tying the fatal ligature, the jury concluded that Elise’s death was contributed to by neglect. The Area Coroner indicated that she will be issuing a Prevention of Future Deaths Report addressed to Essex Partnership University Foundation Trust in respect of Elise’s death. This will be published in due course.
The inquest heard from 30 witnesses, including two expert witnesses, over 5 weeks. Media coverage is available here: BBC, BBC, and ITV.
Back to index