Some readers may find the content of this article distressing.
A coroner has found that a mental health trust’s neglect of a 26-year-old woman contributed to her death by suicide.
Jim Duffy represented the parents of Abbi Smith at the three-week, Article 2 inquest. He was instructed by Amanda Smith at Hodge, Jones & Allen.
Abbi had a learning disability and a diagnosis of autistic spectrum disorder. She had spent much of her teens and early adult life as a psychiatric inpatient.
In 2017 she began a two-and-a-half year stay at Cygnet Hospital in Beckton, a specialist personality disorder unit. She had been referred by her treating team at Essex University Partnership NHS Foundation Trust (EPUT). EPUT is currently at the centre of a statutory public inquiry investigating a large number of mental health patient deaths in Essex. Abbi’s is among those cases.
During her time at Cygnet, Abbi was prescribed with the drug clozapine, which had a positive effect upon her self-harming behaviour and brought about a lengthy period of stability. In 2019, Abbi was discharged to a supported living flat in Braintree.
Abbi stopped taking her clozapine around September 2021. When the EPUT consultant overseeing her care in the community was (belatedly) alerted to this, she arranged to see Abbi urgently, and convinced her to restart.
But Abbi did not go back on clozapine, prompting the consultant to email one of her junior doctors to see Abbi and to try to convince her to go back onto clozapine; Abbi was already deteriorating and would only “get 100 times worse” and possibly require inpatient admission.
Despite that instruction, the further conversation with a doctor did not happen. The Coroner noted that no explanation was given to the Court as to why. The consultant, she said, was “firefighting” in an attempt to deal with “a virtually impossible workload”. Diazepam was added to Abbi’s prescription, but was then inappropriately placed on repeat, meaning Abbi became dependent on it.
Abbi continued to deteriorate and to harm herself, culminating in three A&E attendances in late January 2022. The Coroner found she was supervised by a male security guard rather than by qualified staff, and that this was inappropriate. Her suicidality and self-harm continued while in A&E.
Abbi was sectioned under the Mental Health Act and transferred to EPUT’s Linden Centre. She continued to ligature and head bang during her admission from 3 to 14 February 2022. She explicitly told staff that she would end her life on discharge and asked them not to share this information with her treating consultant. Staff did tell the consultant.
Abbi’s discharge was nonetheless planned to take place on Monday 14 February. She ligatured again over the intervening weekend, but, upon her informing the consultant that she had no suicidal plans, her discharge went ahead.
At the start of the admission, Abbi’s community care co-ordinator had agreed to the discharge plan on the basis of three conditions, none of which had been fulfilled by 14 February. The care coordinator had asked to attend the final ward round review on 14 February 2022, but she did not receive a remote video call invitation and was not contacted. On making enquiries, she was told that Abbi had already been discharged, and that the Home Treatment Team (HTT) would not be involved following discharge, as had been intended.
On the late afternoon of 15 February 2021, Abbi left her flat. When she did not attend for her evening medication, staff at the complex called her mobile phone and checked her room but Abbi was not reported missing until the following morning. In the meantime, she had been found by a passer-by at Braintree Recreation Ground.
The Coroner, Sonia Hayes, found Abbi’s autism was “left as a footnote in her care”. The majority of staff caring for Abbi had received no training in autism. The Coroner did not accept the evidence of Cygnet’s witnesses that they made any adjustments for Abbi while at Beckton. Abbi should have had Care and Treatment Reviews (CTR) due to her autism, part of the purpose of which would have been to avoid admission. Instead, CTRs were “simply given no consideration whatsoever”. The Cygnet records, she found, “contained very little about Abbi as a person”.
Abbi’s unnecessary discharge from the Linden Centre was unsafe. There was a real and immediate risk to her life, and nothing was done to mitigate it. Abbi’s plans to end her life had not been sufficiently explored. Abbi’s care coordinator was left in “a very difficult position”. The discharge amounted to “a gross failure” to provide Abbi with “basic medical care”.
Staff at her supported living placement ought to have reported her missing sooner. Urgent attempts should have been made to contact Abbi’s mother, who would in turn have used an app on her phone to locate Abbi’s device, which was in her room. This would have sounded “immediate alarm bells”. A support worker had given evidence that he had called and texted Abbi on the evening of 15 February before leaving his shift, but the Coroner stated that she was not satisfied that he had done so.
Police should also have been contacted on the evening of 15 February. They would have taken the report seriously and attended urgently. This was a missed opportunity to locate Abbi.
The Coroner concluded that a number of failures contributed to Abbi’s avoidable death. There was a failure by all clinical professionals to care for, treat and communicate with Abbi “as a neurodivergent person with autism”. This exacerbated her presentation and risk of self-harm.
“Neither Abbi nor her mother were listened to”.
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