Lucie Danti represents the family at an inquest where communication & safeguarding shortfalls contributed to death

Lucie Danti, instructed by Healys, recently represented the family at a four-day, Article 2 jury inquest. The inquest centred on the death of CF, a vibrant young woman who developed a short psychotic illness after a period of depression and anxiety for which she had been receiving treatment from a private psychiatrist. CF was admitted to hospital following two attempts to end her life by overdose. After an initial period as a voluntary patient CF was detained under section 2 of the Mental Health Act and remained under section 2 detention until her death. CF’s life ended tragically when she hanged herself during a period of section 17 overnight leave from the hospital.

Lucie established that there had been a breakdown in communication between the hospital staff members and between the hospital staff and the family: an incident earlier in CF’s admission, in which CF had attempted to tie a ligature to hang herself on the ward, had not been shared with the clinicians involved in her care or with the family. Accordingly, when CF went on section 17 overnight leave, no safeguards were put in place to reduce the risk of hanging. Non-compliance with the section 17 leave policy and the absence of an overnight leave plan for the period during which CF died were also established, along with deficiencies in respect of the serious incident report produced by the hospital following CF’s death.

The jury found that inadequate communication within the ward and between the ward and the family, lack of evidence of an overnight care plan or a risk assessment prior to CF’s leave and failure to follow the section 17 leave of absence policy, contributed to CF’s death.

Lucie made submissions on behalf of the family, citing numerous issues with CF’s care that gave rise to the risk of future deaths if no action was taken. Following the jury’s conclusions, the Coroner determined that a letter of concern in respect of the serious incident report was required and that three prevention of future death reports would be issued addressing the following concerns:

1. lack of information sharing between private psychiatrists and the different trusts.
2. failings of record keeping and failure to adhere to policies.
3. lack of provision of advice to families who have no experience of dealing with patients suffering from mental health difficulties.

Lucie accepts instructions to represent interested parties at inquests. Any such request should be made to the Farrar’s Building Clerking Team.

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