Amy Clare Chapman, 35, was a patient at Mill View Hospital in Hove when she died on March 27, 2025.
Ms Chapman, who had a two-year-old son, was “allowed out unaccompanied… against the knowledge and wishes of her family”, law firm Slater and Gordon said.
She was first admitted to the Royal Sussex County Hospital in Brighton on March 3 due to “declining mental health”. After being discharged into community-based care, she was found to be at “high risk of suicide” and was admitted to Mill View.
Slater and Gordon said Ms Chapman was “allowed out twice on March 27” and took her own life on the second occasion when she fell from a bridge above the A27 north of Hove.
Sussex Partnership NHS Foundation Trust has apologised and said it has “made improvements” following her death.
Ms Chapman is described by her family as “beautiful, clever and funny”.
They said: “We firmly believe that if Amy had received the care she needed and deserved, she would still be with us today.
“During Amy’s mental health crisis, which lasted approximately three weeks, our family found ourselves overwhelmed and unprepared.
“With no prior experience of mental health services, we trusted that Amy’s best interests would be at the centre of her care. Tragically, she was let down and this failure cost her life.
“Amy is so terribly missed and our grief is indescribable. We want those who let her down when she needed them most to be answerable for how they have failed our beloved Amy.
“We also want to see meaningful change, not just words, so this can never happen again.”
During the inquest into her death, held from April 21 to 24, the coroner found there was “neglect” in Ms Chapman’s care, Slater and Gordon said.
Ms Chapman’s family said they are grateful for the coroner’s findings, echoing that they believe she was failed in multiple ways.
“We placed our trust in mental health services to care for and protect her, but instead encountered serious shortcomings,” they said.
“These included failures in the management and administration of her medication, poor record-keeping, and inadequate communication.
“As a family, we were kept in the dark and were unable to advocate effectively for her. There was also insufficient monitoring of Amy, which ultimately led to her death.
“We are desperate that lessons are learnt from this and that by us speaking out about the poor care Amy received, this can help change things for other families, so they do not have to live with the daily devastation that we face.”
Madeline Seibert, Slater and Gordon principal lawyer who is acting for the family, said: “At a point in Amy’s life where she desperately needed the treatment, care and support of mental health services, tragically she was let down.
“A vibrant, hardworking young mother who had so much to live for was failed by the services that were supposed to protect her – and the impact of her loss on her family has been utterly devastating.
“We hear so many times that lessons must be learnt, but action as a result of Amy’s death is absolutely essential. We cannot see more families failed in this way.”
John Child, chief operating officer for Sussex Partnership NHS Foundation Trust, said: “I offer my sincere condolences to the family of Amy Chapman.
“I am sorry that we did not fully assess Amy’s risk or involve her family adequately.
“We have made improvements since Amy’s death, including the introduction of a new model of care for patients in our Havens.
“While we have done some work to improve the involvement of families and carers, we know there is more to do and we are committed to further improvement in this area.”
For confidential support, Samaritans can be contacted for free around the clock 365 days a year on 116 123.
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