In the late morning of 1 March 2023, 22-year-old Shannon Lee Jordan was left alone in her hospital room long enough to make a ligature. It wasn’t her first attempt. On three occasions over the previous four weeks she had tried to strangle herself before staff intervened.
Shannon Lee had arrived at Hallam Street Hospital in West Bromwich complaining that she could hear voices telling her to tie a ligature. She was sectioned under the Mental Health Act and put under constant one-to-one observation. But on 28 February a psychiatrist agreed to her request to downgrade her checks to one every 15 minutes.
The next day, an agency healthcare assistant named Uchechkwu Umeagukw looked in on Shannon Lee at 11.19. Over the next hour, according to CCTV, he walked past her door twice without even looking in her room. He nonetheless signed a confirmation sheet saying he had checked on her four times. When the next healthcare assistant looked for Shannon shortly after midday, at first he couldn’t find her. Her body was pressed up against the door of her room. An hour later, paramedics pronounced her dead.
Her mother says Shannon Lee, a carer for the elderly, was always looking out for other people, always showing compassion for others. “But when she needed care,” Nicola Jordan told The Dispatch, “nobody cared enough for her.”
Addressing the courtroom 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. The coroner, Zafar Siddique, expressed concern that the checks had not been done or recorded properly.
Marsha Foster, chief executive of the Black Country Healthcare NHS Foundation Trust, which runs Hallam Street Hospital, told us that “these are serious and sensitive matters and our thoughts remain” with the family. The trust said it had made improvements in its systems for monitoring patients. Umeagukw couldn’t be reached for comment.
Shannon Lee Jordan. Photo provided.
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A hospital that’s ‘not fit for purpose’
Shannon Lee Jordan had been admitted to Hallam Street for her own protection because she was considered a danger to herself. She was in a category of patients for whom the hospital was supposed to be a “place of safety”. But her death is not the only sign of trouble within the Black Country Healthcare NHS Foundation Trust. This umbrella body of mental health facilities has come under increasing scrutiny for serious failings, even as it has faced 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 savings targets of any NHS organisation in the country, set at £30m 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 the cuts are affecting patient care.
Now an investigation by The Dispatch has found that the trust is in a deeper crisis than is publicly known, plagued by clinical failures within hospitals, growing internal discord and the shrinking budgets imposed by NHS England. Apart from the cases of Shannon Lee Jordan and two other people in Black Country mental health hospitals whose deaths have been subject to inquests, The Dispatch can reveal that two other patients admitted for their own protection in the last year have died.
We have obtained the minutes of a meeting of consultants and leadership indicating that the trust has deemed Hallam Street Hospital “not fit for purpose” and made plans to move its three wards to other sites within the next one to three years, or “possibly sooner”.
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