This week our Medical Negligence and Inquest team have been in Chelmsford representing the family of Sharon Kelly at the inquest into the circumstances surrounding her death.
Tragically on the 27th June 2019 Sharon was found hanging at her home a day after a Mental Health Act Assessment deemed she did not meet the criteria to be detained under the Act. On the day of her death, when a 999 call was made to the ambulance service from a concerned relative, it was around three and a half hours before emergency services entered her property and found her. Concerns had been raised by the family about the decision making process of the Mental Health Trust and the processes and response times of emergency services.
After hearing four days of evidence at Essex Coroner's Court from witnesses employed by Essex Partnership University Foundation Trust (EPUT), the East of England Ambulance Service and Essex Police, the jury returned a verdict of suicide, raising three particular criticisms in their conclusion. They found that the timing of the Mental Health Act assessment was inadequate, the ambulance service failed to initiate a risk assessment when arriving at the scene and there was wide spread miscommunication between all services.
Speaking after the jury's conclusion, Sharon's mother Sue Walkinshaw-Kelly said: "Sitting through the four days of evidence and legal submissions was a very harrowing experience. It confirmed for me my fears that there were multiple failures by the services involved and that these may have contributed to Sharon's death.
"However, I can at least take some comfort that the jury identified numerous failings and brought them to light in their conclusions. Hopefully, appropriate changes will be made and implemented to ensure such a needless tragedy does not happen again."
Solicitor for the family, Fosters' Head of Medical Negligence David Gabell commented: "It was a privilege to represent the family in this tragic case. The family has shown immense bravery throughout the entire inquest process. The family had felt that there were real concerns to be raised across various state agencies regarding the circumstances leading up to Sharon's death, and the jury's findings today confirm their concerns were entirely valid.
"I am immensely glad that we have been able to assist the family through this complicated and often distressing case and get them the justice they deserve."
Senior Coroner for Essex, Caroline Beasley-Murray OBE concluded the inquest by saying: "The court would like to express sympathy for the loss of Sharon in these sad circumstances.
"Not only have you lost her but you have had the ordeal of sitting through this inquest. You said that when Sharon was well she was the loveliest, happiest, kindest girl you could wish to meet and I hope you cherish that memory."
Summary of inquest
On the first day the jury head evidence from a number of medical professionals, including the two psychiatrists that performed the Mental Health Act assessment on the 26th June 2019, the day before she took her life. The jury also heard evidence from the EPUT psychiatrist that had urgently requested the Mental Health Act assessment on the 25th June 2019, following concerns being raised about her welfare. This psychiatrist, who had been involved in Sharon's care since 2016, told the court that he had expected a Mental Health Act assessment to be carried out on the evening of the 25th June 2019, i.e. the same day that the referral was made. In the event, the assessment was not carried out until the next day, when it was decided that Sharon did not, at the time of that assessment, meet the statutory criteria to be detained under the Mental Health Act.
One of the psychiatrists that had performed the Mental Health Act assessment told the court that he was "surprised" that Sharon had taken her life the next day.
On the second day the Jury heard evidence from a number of witnesses from Essex Police control room, including communications officers and call handlers that had been involved. Questions were raised about the how the call was graded, the effectiveness of the oral handover that the police dispatchers provided when changing shifts, and an apparent delay in getting a police unit despatched to the incident. The ambulance service had requested police attendance before they entered the property, due to a 'warning flag' on their system indicating that that Sharon may be violent. It took over an hour to allocate an available police unit to the incident and a large portion of that time is unaccounted for in the police call logs.
The jury also heard evidence from the Chief Inspector in charge of the Essex Police Control Room, who had carried out a review into the police's involvement in the incident. He confirmed that his review was not able to account for this missing period of time in the call logs and he offered his apologies to the family for this. He also explained that this incident had highlighted shortcomings in some key areas of processing such calls and that some changes had already been made in order to remedy these shortcomings.
On the third day the jury heard evidence from a number of employees of the Ambulance Service regarding their involvement in the incident. The initial 999 call to the ambulance service was made at 1.45pm on the 27th June, just three minutes after Sharon had sent a last text message to her son stating her intention to end her life. An ambulance arrived on the scene at approximately 3.30pm but the crew did not enter Sharon's property due to the 'risk flag' on the address. It is common practice that with such a marker on the address, the ambulance crew would carry out a risk assessment at the scene before deciding whether they need police assistance.
The ambulance crew parked at a distance from the property and the crew decided to wait until police attended. They waited for more than an hour before being reassigned as the police could not provide an ETA. At no point did they approach Sharon's house. In the event, police arrived on scene at approximately 5pm and an ambulance arrived shortly thereafter. They gained entry to Sharon's property at about 5.12pm and found her hanging. Efforts were made to resuscitate but Sharon was pronounced dead at 5.22pm.
The inquest heard from various witnesses from the ambulance service. Various shortcomings were identified including a failure to call for police assistance as soon as the 999 call was received. The Ambulance Service also recognised a lack of clarity over the risk assessment and decision making process regarding call-outs to an address where there is a 'warning flag' on the system. Witnesses from the ambulance service also confirmed that, with hindsight, it should have been recognised that recent ambulance service records showed that crews had attended Sharon's address just the day before without issue. Such information should have been provided to the ambulance crew on scene to assist in their risk assessment as to whether or not to try and enter the property.