Eltham woman’s suicide at her mum’s home was a forseeable risk, inquest jury finds

A mother discovered her daughter hanging in their home and she died four days later in a tragedy which her secure hospital has been told was avoidable.

An inquest heard the death of Claire Lilley, from Eltham, would have been avoidable if the staff of Oxleas House had told her mother she was a suicide risk when left alone for long periods.

Staff shortages at the Stadium Road, Woolwich hospital also contributed to the 38-year-old committing suicide while on leave with her family – because her mum was not told of the risks.

Claire Lilley 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.

The jury at her inquest which ended on Monday, [November 30] delivered a narrative verdict in which it said that there was a lack of consistent communication with the family and poor management of risk while Claire 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 12, 2019. She was taken to hospital, but sadly died four days later on February 16.

Her mother, Brigitte Fortin, who had expressed her concerns about Claire’s worsening anxiety and mental state while on leave, 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 of 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.”

Claire had told her clinical psychologist about her ambivalence towards life and repeatedly said she had wished the attempted suicide in October had been successful.

The psychologist said Claire should not be left alone for a long time as she was at high risk of suicide. But her mother was not told this – even though Claire went on overnight leave the day after the assessment.  The risk assessment did not list the risks for when she was at home.

The family’s 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.

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

She had 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 pronounced dead on  February 16 2019.

The cause of death was hypoxic brain Injury caused by hanging.

The narrative verdict handed down by the jury at the inquest said the ‘main contributory factor’ to her hanging was ‘mental illness’. But it also said communication from the Trust – both with the family and between the staff on the ward – was deemed ‘inadequate’.

The jury also said a lack of “central formulation of the most pertinent information relevant to risk” was worst when several members of staff were on leave, with “insufficient management cover to review risk and make decisions in this particular case”.

As a result, the coroner said he will produce a prevention of future death report focusing on a central document which formulates the risk.

Claire had a ceramics degree from Camberwell College of Art. Claire loved going to exhibitions, reading, and being outside, especially walking her dog Kizzy.

Matthew Trainer, chief executive at Oxleas NHS Foundation Trust said: “We are very sorry that Claire died and would like to apologise to her family for the failings in our communications with them when she was on leave. We await the Coroner’s report and will do everything we can to make changes that reduce the chance of this ever happening again.”

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.


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