Woman's final wish after mental health care failings

Andreea Lazarec remembers her daughter's final wish before taking her own life.

They spoke on the phone in the morning of 4 January 2025, with Rianna Poiana-Lazarec urging her mum to go to the Care Quality Commission (CQC) and BBC to tell her story after being admitted to Sherwood Oaks mental health hospital in Mansfield, Nottinghamshire.

An inquest into her death concluded there had been inadequacies at the hospital and missed opportunities in her care which contributed to her death.

"I'm glad I've managed to do what Rianna asked of me," said Andreea following the conclusion of the inquest. "She was a wonder child."

Warning: This article contains mentions of suicide and self-harm

The inquest held at Nottingham Coroner's Court heard Rianna was a "happy child" in her early years, according to her mum.

Originally from Romania, Andreea said her daughter was a "prodigy", who started to play the piano and read books when she was very young.

But at the age of 16, her mum started to notice changes in her behaviour.

Rianna was aspiring to go to the University of Cambridge to study, however her place was withdrawn after her mental health struggles and an overdose impacted her grades.

That was a "big trigger point" in her daughter's life, Andreea told the inquest.

Rianna moved from Colchester to study modern languages at the University of Nottingham.

The inquest heard she had a long history of self-harming and an Emotionally Unstable Personality Disorder (EUPD) diagnosis, followed by an Attention Deficit Hyperactivity Disorder (ADHD) diagnosis as well.

She was admitted to the 17-bed Beech Ward at Sherwood Oaks under section three of the Mental Health Act in November 2024.

Rianna was initially admitted with high observation levels - one every 15 minutes. But later that month, her observation checks were reduced to every hour.

The inquest heard how Rianna had disclosed her wish to end her life following her birthday on 11 December.

Following multiple self-harming incidents on 15 December, she was moved to increased observations, before being reduced again.

The inquest was told that her chosen method to self-harm was by using a household item and despite staff being aware of this, she was not reduced access to this item.

The hearing was told she cooperated with staff and wanted to get better, but also kept self-harming.

Rianna - who had agreed to remain voluntarily at the hospital as an informal patient at the time - was detained under section three again on 24 December 2024, which prevented her from leaving over Christmas.

She was placed on general observations again - one every hour - and said later that month that she would rather die than remain at the hospital.

During her detention, Rianna was reported self-harming 23 times in 23 days. She used the household item to self-harm on 1 and 3 January 2025, however her access to this item was not restricted.

On 4 January, she was found unresponsive in her en-suite room by a staff member during one of the observations. She had been self-harming with the household item, the inquest was told, and an emergency response followed.

Rianna was transferred to King's Mill Hospital where she was pronounced dead two days later.

On Friday, a jury at Nottingham Coroner's Court found Rianna did not have the capacity to form the intention to take her own life, and did not intend to do so.

They found the low level of observations "significantly contributed" to her death, and said the level of supervision and control of the household item given her history was "not adequate".

The jury concluded there were "multiple opportunities" to prevent Rianna's death, and that the failings at the hospital more than minimally contributed to her death.

A Prevention of Future Deaths report in connection to her death will also be published later this year.

A spokesperson for Nottinghamshire Healthcare said they were "deeply sorry" for the failings in Rianna's care and had introduced changes since her death to address those issues.

Speaking in Romanian to the BBC, Andreea said her daughter's final wish was to highlight the failings in her care.

"She had mentioned all of those failings during our phone calls," her mum added.

"This is not about justice, it's about helping people in the future - this is what [Rianna] wanted."

She said Rianna was vocal about her needs, but felt that she was not being listened to.

"I knew about her attempts, but I didn't think she was going to be successful in her attempts," her mum added.

"I'm just disappointed, because everything that Rianna said was real, and I wasn't the only one she was telling all of this to. She was complaining to all the staff there."

But Andreea hopes the findings of the inquest mean her daughter has now been listened to.

"The inquest has not changed anything and it does not make the situation any better," she added. "I'm just glad I've managed to do what she asked of me."

If you have been affected by any of the issues in this story, help and support is available at BBC Action Line.

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