What happened
Claire Greaves, 25, from Pontypool, was a mental health campaigner and writer who had lived with anorexia and a personality disorder from an early age. According to BBC News, she was moved in May 2017 from Nevill Hall Hospital in Abergavenny to Cygnet Hospital in Coventry, more than 100 miles from home, as an NHS-funded out-of-area placement. Her parents were told it was the only available hospital that could manage both of her conditions.
She was placed in seclusion and long-term segregation, and her parents were told they could not contact her for several weeks. After a call in January 2018 her father said she had told them the room had no furniture, and that her mattress was brought in at night and taken out again. She had been assessed as at high risk of self-harm or suicide between 17:00 and 18:00 each day. In February 2018 she died alone in her room, using a piece of fabric that had been left on the floor outside it.
The outcome
The inquest jury returned an open conclusion rather than suicide. It found that long-term segregation and seclusion contributed to a decline in her mental state, and that staffing levels “probably caused or contributed” to her death. It found a failure to increase observations despite numerous self-harm attempts in the days before, and a failure in allowing her to be alone in her room, contrary to her care plan. Had there been sufficient staff, the care plan could have been followed and the risk period of 17:00 to 18:00 would have been covered.
Cygnet disputes the staffing finding, and says levels that day were 28% above rota.
What went wrong
The Care Quality Commission had raised concerns about the hospital before her death. It found recruitment and retention difficult, with high staff turnover leading to a shortfall in training and supervision, and some patients feeling unsafe on the wards. An inspection published five months after her death found staffing was still a problem. According to BBC News, 61% of employees were not comfortable with their daily workload.
The ward manager said he had emailed managers a week before her death to say he was “really concerned” that staffing was “very unsafe”. Cygnet said it had listened and acted every time he raised concerns, and that an investigation into his allegations found them to have “no substance”.
What it teaches
Long-term segregation and seclusion are active interventions with measurable harms, not a quiet alternative to restraint. Where a care plan depends on a one-to-one hour, the absence of staff to cover it is a restraint-related death risk, not an administrative failing.
The observation level is a clinical decision. When the plan names an hour as the highest risk, the rota is part of the clinical plan.
Questions for the room
- Her risk period was 17:00 to 18:00 every day. Who was rostered to cover it, and what did the handover say?
- Her parents could not contact her for weeks and she had no furniture in the room. What does that tell you about how the placement was being reviewed?
Evidence and limits
Confidence: probable. This rests on two BBC reports of the same inquest, which is one outlet only, so the two-source test is not met. The jury’s findings are quoted in detail but no coroner’s record was opened. Cygnet disputes the jury’s finding on staffing, and that dispute is carried here rather than settled. The open conclusion was reported on 2 April 2019.
This page gives no date for the death beyond the month, because no source gives one. No member of staff is named.
This entry was drafted from the case record and the case précis. The two BBC reports were not re-opened for it.
Dynamis training related to this case: [physical interventions](/training-solutions/physical-interventions).
Sources
Reviewed 20 October 2026.