Sharon Kelly suffered from a long history of mental health problems, including previous suicide attempts, most recently in May 2019 which resulted in her being admitted for a period as an inpatient. She was diagnosed with Emotionally Unstable Personality Disorder, which rendered her poorly able to tolerate any form of stress.
On 25th June 2019 the community Home First Team was concerned that Sharon’s risk of suicide meant that she could no longer be safely managed at home. A Mental Health Act assessment took place the next day but the clinicians did not consider her to satisfy the Mental Health Act criteria for involuntary detention in hospital.
The following day her daughter made a 999 call at 1.45pm because she was very concerned that her mother had taken an overdose. Due to the demand on services that day, though not an unusually busy day, an ambulance did not reach the property until 3.36pm. Despite there being a risk marker in the ambulance service system to indicate that police presence should be sought to accompany an ambulance crew owing to a previous incident at the property, the police were not contacted until 3.28pm. A police response was not dispatched immediately due to a lack of available units. The original ambulance crew decided not to enter the property given the risk marker and were diverted to another call. When the second ambulance crew and police officers entered the property almost 3 and a half hours after the 999 call, Ms Kelly was found having hanged herself with no signs of life.
An Article 2 inquest before a jury took place over four days in November 2020. The jury concluded that Ms Kelly killed herself. The jury found that the timing of the Mental Health Act assessment was inadequate; that there was a failure by the ambulance crew to initiate a risk assessment on arrival at the property; and that there was widespread insufficient communication between all services.
Jonathan was instructed by David Gabell of Fosters Solicitors for the family of Ms Kelly. Judith was instructed by Hempsons Solicitors for the Essex Partnership University NHS Foundation Trust and the East of England Ambulance Service Trust.
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