Tom Semple represented the family of SM at the inquest touching her death

SM was known to have mental health difficulties for many years, resulting in 8 voluntary hospital admissions between 2013 and 2018, typically lasting several weeks.

Between admissions, she was under the care of her care coordinator, a community psychiatric nurse. In 2019, SM’s mental health deteriorated and voiced plans to take her own life while her partner was at work. This resulted in a further voluntary admission to hospital, but was discharged home after 5 days. The following Monday, after her partner left for work, SM sadly took her own life.

At the inquest, the Coroner found that SM felt unsupported by her care coordinator and noted that her relapse plan was 5 years out-of-date. It was found that the SM and her family were failed by problems in communication. Her partner was not informed of her previous plans to end her life while he was at work. SM also felt unsupported on the ward and was not consulted regarding changes to her medication. Moreover, the hospital also failed to contact her partner’s views prior to discharge, which the Trust accepted it should have done. It was held that these failures meant safeguarding measures were not put in place.

Further details of the case can be found at www.gazettelive.co.uk (day 1) and www.gazettelive.co.uk (day 2).

Tom Semple is a member of Parklane Plowden’s specialist Inquests and Inquiries team. He is named as a ‘rising star’ in the Legal 500 for clinical negligence and inquests.