Poor Communication Found By Inquest Jury After Patient Suicide

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A lack of communication and staff shortages at a hospital which was responsible for the care of a woman with mental health issues, who committed suicide while on leave to stay with her family, have been criticised by the Jury at an inquest which concluded this week.

Claire Lilley, 38, from Eltham, South East London, tragically passed away after taking her own life while on authorised leave from Oxleas House, part of the Oxleas NHS Foundation Trust, where she had been detained under the Mental Health Act since October 2018.

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At an inquest which concluded on Monday, November 30th, the Jury delivered a narrative verdict in which it said that there was a lack of consistent communication with the family in relation to Claire’s home leave as well as a poor management of risk whilst she was on leave.

The former librarian, who was described by her family as ‘gentle, sensitive, proud and lovely’ was found hanging by her mother on February 12th, 2019. Though she was taken to hospital, Claire sadly died four days later on February 16th.

Speaking on behalf of the family following the inquest, their lawyer, Chris Callender of Simpson Millar Solicitors, said it was their hope that ‘lessons would now be learnt’.

He said: “It has been a difficult and distressing experience for the family to revisit the tragic circumstances which led to Claire's death. 

“To hear from her responsible clinician that there had been poor communication with the family regarding her care needs confirms their concerns that the clinical team were unable to adequately assess the risk that Claire posed to herself while away from the hospital, and that as a result there were missed opportunities to save her life.

“They now hope that lessons will be learned and that the Trust will ensure that staff communicate with families and support networks involved in patients' care to ensure that risk assessments and care plans accurately reflect patient needs."

Claire experienced depression with psychosis and had previously been hospitalised during a depressive episode in 2010.

In October 2018, Claire attempted suicide by overdose, triggered by a delusional belief that her neighbour was filming her, following which she was detained under the Mental Health Act in an Oxleas NHS Trust hospital.

During her detention, leave from the hospital was authorised. This included overnight leave at the end of December, and unescorted leave from the end of January. On 12 February 2019, while on leave at home, Claire's mother found Claire hanging in the corridor. She was taken to the hospital but was sadly pronounced dead on 16th February 2019.

The cause of death was Hypoxic Brain Injury caused by hanging.

However, as part of the narrative verdict handed down by the Jury at the inquest, it was said that while the ‘main contributory factor’ to her hanging was ‘mental illness’, communication from the Trust – both with the family and between the staff on the ward – was deemed ‘inadequate’.

This led to concerns over the risk management of her home leave, with the Jury finding that a lack of ‘central formulation of the most pertinent information relevant to risk’ became especially relevant when several members of staff were on leave, resulting in ‘insufficient management cover to review risk and make decisions in this particular case’.

The Coroner further confirmed that he would produce a prevention of future death report in relation to the lack of a central document which formulates the risk, reflecting both the jury and family's concerns.

Claire's family describe her as a very gentle, sensitive, proud and lovely person, who was extremely intelligent with a tremendous sense of humour. She had a talent for art and had a Ceramics degree from Camberwell College. Claire loved going to exhibitions, reading, and being outside, especially walking her dog Kizzy.

Her mother, Brigitte Fortin, said: “I hope the death of my gorgeous Claire, who knew she was unwell but did not understand or comprehend the nature of her illness, will not be in vain.  I hope that her legacy will truly effect changes for other people, who sadly might find themselves in the same unfortunate situation.

“If there had been proper assessments, accurate reporting of events and meaningful engagement and discussions with her family, it would have helped Claire’s recovery and reduced the risks associated with her mental illness.  Open communication involving her family and friends when on leave would have protected her life.

“Our thanks go to our legal team and the Inquest team for their infallible support and guidance through a very difficult period of our lives."

The family was represented at the inquest by Chris Callender and Amy O'Shea of Simpson Millar Solicitors and Kirsten Heaven of Garden Court Chambers. The family was supported by the charity, Inquest

Inquest Overview

Throughout the inquest, the Jury heard that Claire's delusional belief and risk of suicide were present throughout Claire's time under section.

Despite this, from 30th January – 12th February 2019, the Trust did not actively seek feedback from Claire's mother as to how the leave at home was going. Claire's mother gave evidence at the inquest in relation to the weeks leading up to Claire's death, including her concerns about Claire's worsening anxiety and mental state while on leave.

While Claire's mother had carefully documented each instance of leave, much of this information was not known to Oxleas Trust as they had not sought feedback on the majority of Claire's leave periods during January-February 2019.

It was accepted by Claire's responsible clinician that this was a missed opportunity in relation to obtaining information relevant to risk. The only occasion where feedback was given in the two weeks leading up to Claire's death was when Claire's mother brought Claire back from leave on 6th February 2019, as she was concerned about Claire's presentation and distress. However, no feedback was subsequently sought for the further periods of leave following this.

The jury further heard that there was no formulation of risk in the risk assessment, but instead a chronology of events which did not include key disclosures Claire made to the clinical psychologist, including her ambivalence towards life and her repeated disclosures that she had wished the attempted suicide in October had been successful.

The psychologist's assessment that Claire should not be left alone for prolonged periods of time as she was at high risk of suicide was not included in the risk assessment or communicated to Claire's mother – despite the fact that Claire went on overnight leave the day after the psychologist's assessment.  The risk assessment did not set out any triggers, or a risk management plan for when Claire was on leave from the ward.

While initially ruling Article 2 of the European Convention of Human Rights was not engaged in this inquest on Friday 27 November, following further submissions from counsel for the family that same day, the Coroner produced a written judgment confirming that there was an arguable breach of Article 2 by Oxleas Trust, and that Article 2 was therefore engaged. This meant that the jury had the option to produce a narrative in relation to Claire's death.

The family’s primary concerns included whether Claire's risk of suicide was assessed specifically in the context of her returning home on leave; the lack of communication to the family as to Claire's risks of suicide; and the lack of consistency in feedback sought from the family in relation to leave.

The jury in returning its verdict found that while the main contributing factor leading to her hanging was mental illness, the following factors were considered relevant:

  • Communication between the family and the Oxleas Trust, and within the ward staff, was inadequate
  • There was a lack of consistent communication between the Trust and the family regarding feedback on home leave and risk management while on home leave
  • On the ward, relevant information was diffuse and there was no central formulation of the most pertinent information relevant to risk. This became especially relevant when several members of ward staff were on leave and there was insufficient management cover to review risk and make decisions in this particular case.


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