Chichester teen found dead in Worthing hospital was 'retraumatised by horrific merry-go-round' of admissions and discharges

Morgan-Rose Betchley, 19, was found dead while an impatient at Meadowfield Hospital in Worthing on March 9 2023. Described as ‘quiet’, ‘gentle’ and ‘inwardly brave’ by loved ones, she had a history of poor mental health, and was in the midst of her third stint at Meadowfield Hospital, having attempted to take her own life on several prior occasions. Speaking to a jury inquest in Horsham, family members have described the ‘roundabout’ of admissions and discharges Morgan – who was diagnosed with autism in January 2023 – experienced while under the care of Sussex Partnership NHS Foundation Trust.

Morgan was first referred to A&E at St Richard’s Hospital, in Chichester, on February 1, after reporting audio hallucinations to her partner Dominic. She returned to the same A&E on February 6 after deliberately overdosing on paracetamol, and then again on February 9. This time, she stayed at A&E until 13, before she was admitted to Meadowfield Hospital, where she stayed until February 21 – when she was abruptly discharged.

"There was no discussion about whether it was safe for her to come home,” her partner Dominic Goddard said, making clear that Morgan had, on the morning of February 21, imagined she’d be staying a while longer. “There hadn’t been a significant change in her mental state and so I just thought we would be going full circle in terms of her coming out and then doing something to hurt herself.”

Morgan’s suicidal ideation continued and she returned to Chichester A&E from February 22 to 25, before she was re-transferred to Meadowfield Hospital following another suicide attempt. She self-discharged on February 27, following an incident during which several staff were injured. Dominic said she had described staff as ‘horrible’ and continued to express suicidal thoughts.

Following the incident on February 27, Morgan was placed in police custody, sent to Worthing A&E and then transferred to the Woodlands Centre in Hastings over the course of just a few days. Morgan’s family praised the quality of care at the Woodlands Centre, and were surprised when she was again transferred to Meadowfield Hospital on March 3, despite the events of February 27.

Louise Hodgson, Dominic Goddard’s mother, and a midwife with 30 years experience in the NHS, said this cycle of admissions, discharges and re-admissions, exacerbated Morgan’s symptoms.

" In my view, Morgan was sadly and tragically let down by her treatment and the lack of treatment. She was not provided with the care a young autistic traumatised mother should receive in order to recover. She was re-traumatised by a horrific merry-go round of admissions and discharges,” she said.

"One of the things that was most difficult for Morgan due to her neurodiversity, was dealing with change. Morgan needed structure and familiarity of routine and environment to feel calm. Obviously the number and frequency of changes in environment, staffing and routines which Morgan had to navigate in an extremely short space of time would have been traumatising for any well person. Morgan being already distressed, suicidal and agitated, had to continuously re-orientate herself not only to new hospital environments but also to a police cell.”