On 13 October 2025 a jury in the Croydon Coroner’s Court returned a narrative conclusion that Maria Morris died by accident, and that unclear documentation and communications around observation levels may have contributed to her death.
Maria Morris had been admitted to Bethlem Royal Hospital on 18 September 2021. She was found unresponsive on the evening of 21 September 2021. The jury heard conflicting evidence around what level of observations staff understood Maria to have been on during her admission. Maria was found at around 9.23pm, during the changeover of shifts, which is acknowledged by SLAM policy to be a time when particular vigilance from staff is required.
The jury found that due to conflicts in the evidence they could not establish the effect of the issues around observations.
The jury also recorded that Maria had expressed concerns about her treatment and the treatment of other patients on the ward. The conclusion also recorded that after her death, a large unexplained bruise was identified on Maria’s body.
In response to the inquest hearing, SLAM announced that the Trust would be rolling out CCTV on their wards. It is understood that CCTV will be in place by 1 November 2025.
The family’s statement can be found here.
The family were represented by Amy Ooi of Bhatt Murphy and Keio Yoshida at Doughty Street Chambers.
