On the morning of 1 March 2023, 22-year-old Shannon Lee Jordan was left alone in her hospital room long enough to fashion a ligature. It was not her first attempt. Over the previous four weeks, she had tried to strangle herself on three occasions before staff intervened.
Shannon Lee had arrived at Hallam Street Hospital in West Bromwich complaining of voices telling her to tie a ligature. She was sectioned under the Mental Health Act and placed under constant one-to-one observation. However, on 28 February, a psychiatrist agreed to her request to downgrade checks to every 15 minutes.
The next day, agency healthcare assistant Uchechkwu Umeagukw checked on Shannon Lee at 11:19. Over the following hour, CCTV showed he walked past her door twice without looking in. Nonetheless, he signed a confirmation sheet indicating he had checked on her four times. When the next healthcare assistant looked for Shannon shortly after midday, he initially could not find her. Her body was pressed against her door. An hour later, paramedics pronounced her dead.
Her mother, Nicola Jordan, described Shannon Lee as a carer for the elderly who always looked out for others. “But when she needed care, nobody cared enough for her,” she told The Dispatch.
At an inquest last October, Umeagukw admitted: “I know maybe if I had checked on her, she might still be alive today.” A jury found that his error “possibly contributed” to Shannon’s death. Coroner Zafar Siddique expressed concern that checks were not performed or recorded properly.
Marsha Foster, chief executive of the Black Country Healthcare NHS Foundation Trust, which runs Hallam Street Hospital, stated: “These are serious and sensitive matters and our thoughts remain with the family.” The trust said it has made improvements in monitoring systems. Umeagukw could not be reached for comment.
A Hospital ‘Not Fit for Purpose’
Shannon Lee Jordan was admitted to Hallam Street for her own protection as she was considered a danger to herself. She belonged to a category of patients for whom the hospital was meant to be a “place of safety”. However, her death is not an isolated incident. The Black Country Healthcare NHS Foundation Trust, which oversees mental health facilities, has faced increasing scrutiny over serious failings amid funding cuts.
In 2025, NHS England downgraded the trust from segment 3 to segment 4, the lowest performance category. Last year, the trust had one of the largest cost-saving targets of any NHS organisation in the country, set at £30 million, or 8.2% of turnover. It has a further 4% to save in the current financial year.
A spokesperson said NHS England continues to support the trust to improve patient safety and service quality but declined to address whether cuts affect patient care.
An investigation by The Dispatch has revealed that the trust is in a deeper crisis than publicly known, plagued by clinical failures, growing internal discord, and shrinking budgets. Apart from Shannon Lee Jordan and two other deaths in Black Country mental health hospitals that have been subject to inquests, The Dispatch can reveal that two other patients admitted for their own protection in the last year have died.
Minutes from a meeting of consultants and leadership indicate that the trust has deemed Hallam Street Hospital “not fit for purpose” and plans to move its three wards to other sites within one to three years, or “possibly sooner”.
