Mum 'left like a rabid dog' in mental health ward where she was mocked

Irish Daily Mirror

26-07-2025

A mum was "left like a dog with rabies" in a mental health facility where she was mocked by staff, her daughter has claimed, following an inquest that found neglect contributed to her painful and traumatic death.
Margaret Mary Picton, known as Rita, died of aspiration pneumonia after choking on paper in September 2022. Despite Rita's passing nearly three years ago, her heartbroken family had to wait until earlier this year for an inquest that would reveal the neglect she endured at Leigh Moss Hospital in Liverpool, which is run by Mersey Care mental health trust and specifically caters for patients with dementia.
Rita was 76 when she passed away, but her health had been deteriorating for several years after she began suffering from vascular dementia. "Mum was a very straightforward person, she would always tell it like it is," explained Rita's daughter, Rachel Burkey, 51.
"She was very good natured and would always give her kids whatever we needed. She was a really good mum.
"But a few years ago I noticed changes in her behaviour and her mood. Then my sister called to say she was confused and had come at her with a knife. It was horrendous," reports the Mirror.
After being in a care home in St Helens, Rita's unpredictable and sometimes aggressive behaviour led to her being sectioned under the Mental Health Act and taken to Leigh Moss on September 10, as reported by the Liverpool Echo.
Upon her arrival on the ward, medics determined that Rita required monitoring at least every quarter of an hour due to her fluctuating mental state and history of self-harm incidents.
An inquest at Liverpool Coroner's Court in January was told that ward personnel failed to seize chances to address Rita's erratic and perilous conduct, including an incident where she stabbed herself with a pen. Personnel failed to escalate these incidents and monitoring was not properly implemented.
One member of staff, who bore responsibility for interacting with Rita on the wards, made no "meaningful attempts to engage positively" with her, the inquest determined. Even more damning, he was characterised as "unprofessional and disrespectful" when making gestures towards her.
Rachel provided further details about this staff member's conduct after viewing CCTV footage during the inquest. She continued: "On the CCTV I have seen, she is in the corner, she looks like she has been there for hours. To me, she looked like she had been left like a dog with rabies.
"He (the staff member) was pretending to shoot a bow and arrow at her and pretending to shoot himself in the head. He even mimicked her when she was eating paper."
Coroner Helen Rimmer determined that monitoring of Rita was "limited and of poor quality", resulting in missed chances to recognise a decline in her condition and raise alarm bells. For a full 60 minutes there was no supervision of her whatsoever owing to a "communication breakdown" amongst personnel.
The coroner stated: "This was fundamental basic care and supervision, which more likely than not would have led to an escalation and review of Rita's behaviour and presentation at that time had the requisite observations been undertaken."
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The inquest heard that CCTV footage then revealed at least five, possibly six instances where Rita could be observed placing paper in her mouth, with staff present on every occasion.
Whilst they did step in and remove some paper from her, they again failed to escalate concerns.
On the evening of September 10, one staff member witnessed Rita consuming paper and did not take it away from her, instead gesturing an eating motion to someone else.
He then positioned himself with his back to Rita, failing to adequately supervise or monitor her.
In her record of inquest, the coroner states: "Staff were aware of the choking risk of paper eating but failed to escalate matters, intervene, and appropriately monitor Rita."
She added: "It is more likely than not that had staff been appropriately observing and supporting Rita, they would have removed all paper from her or in the alternative escalated concerns about Rita eating paper earlier with the nurse in charge who would then have removed any paper from Rita, identified any continuing concerns and reviewed risks, which would have included consideration of the level of Rita's supportive observations. This would have more likely than not prevented Rita from eating paper and subsequently choking."
Rita shockingly collapsed shortly after, and the staff who had witnessed her eating paper failed to inform those performing CPR on her about this, hence choking prevention measures were not considered. Paramedics were summoned but were delayed due to being locked out of the hospital building. When they finally arrived, CPR had been ongoing for 25 minutes and Rita had suffered two cardiac arrests before the paramedics were informed that Rita had been consuming paper prior to her collapse. This delay prevented the paramedics from promptly removing the paper, which was obstructing Rita's airway.
The coroner remarked: "This was basic care and treatment that should have been undertaken and raised sooner. Not to have provided this basic care and information to professionals treating Rita was a gross failure which more likely than not hastened Rita's death."
Rachel described these failures as "sickening", adding: "I can't believe they didn't even tell the paramedics that she had chewed paper until the very end. She had two cardiac arrests before they said anything. It is hard to think of that being her end."
Rita was transported to the Royal Liverpool Hospital where she developed aspiration pneumonia and tragically passed away on September 26, 2022. The coroner declared: "The aspiration pneumonia was more likely than not caused by Rita eating the paper, the resuscitation efforts that followed Rita eating the paper and collapsing or a combination of both.
"The failure to immediately notify staff and paramedics that Rita had ingested paper prior to her collapse represented a failure to render care that would more likely than not have prolonged her life."
Ms Rimmer continued: "Having identified a specific gross failure which clearly amounts to neglect, it is also found that the accumulation of the catalogue of missed opportunities throughout the care of Rita by those involved in her care at Leigh Moss Hospital, namely the acts and omissions mentioned above, have as a whole also amounted to neglect."
Aware of the shortcomings in their mum's care, Rachel and her sister Jak sought justice but faced a lengthy wait for the inquest due to various delays. They hired a barrister for the hearing to ensure they achieved the right outcome for their mum.
"I thought, I am going to get my mum justice," Rachel added. "I am going to make them tell me what they did. This was about accountability.
"We came out of that inquest and we said 'we've done you proud mum', she was neglected and people will know that. I feel like we got justice and by sharing it with the ECHO everyone will know what happened."
Rachel said: "Mum was a fighter, even on that day on the CCTV she was still giving as good as she got. We will remember her fight and her spirit, she went through a lot and that's the sad thing. She shouldn't have been left like a dog in the corner, with no one doing anything except teasing her and basically watching her die.
"But I think mum would be looking down now and saying 'good on you girls' for us fighting like this. I can see her saying that, she was really feisty. She was a lovely mum and a strong woman who wouldn't back down from what she thought was right."
A spokesperson for Mersey Care NHS Foundation Trust stated: "We'd like to again offer our sincere condolences to the family, friends and loved ones of Margaret Mary Picton. While we are unable to comment on individual patient care because of rules governing patient confidentiality, we can confirm that we fully co-operated with the Coroner's investigation. We also accept the findings of the Assistant Coroner, Helen Rimmer and would like to sincerely apologise for the shortcomings in care.
"A patient safety learning review was undertaken following the tragic circumstances which led to Mrs Picton's death. This is in line with the Patient Safety Incident Response Framework (PSIRF) which is the NHS approach for responding to patient safety incidents, focussing on learning and making immediate changes to ensure patient safety, through a compassionate, system based and proportionate approach.
"As a Trust, we remain committed to learning with efforts to ensure that incidents of this nature do not recur."
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