Rajkiran Barhey, instructed by Ali Cloak of RoydsWithyKing, acted for the family of GS, a young woman who took her own life whilst on home leave from a mental health hospital.

Following detailed submissions from the family last year, the Coroner convened an Article 2-compliant inquest and a jury. The inquest commenced last week and lasted 5 days. GS had a complex history of mental and physical health issues which worsened in the year prior to her death and made it difficult for her to leave the house.

Social Services carried out a Care Act assessment and offered GS a personal assistant, however they took approximately 7 months to authorise the payments. The jury concluded that “GS was failed in regard to the length of time taken to provide personal assistant hours. This led to her feeling isolated and abandoned and a burden to her father, exacerbating her history of suicidal ideation.”

They also found that communication between services was “unsatisfactory leading to an extended timeframe for any provisions to be made for GS’ care.”

GS was in hospital for 5 weeks before her death due to her risk of suicide. Although she was on x4 observations an hour, she was permitted unescorted home leave. Before the inquest, the trust admitted breaches of duty in relation to a failure to reassess GS’ risk, maintain an updated care plan and provide community support for GS while she was on home leave however the jury were unable to conclude that these breaches made a difference to the outcome.