Juliette Kirsty SEWELL · Prevention of Future Deaths report

On 23 April 2024 I commenced an investigation into the death of Juliette Kirsty SEWELL. The investigation concluded at the end of the inquest. The conclusion of the inquest was; Suicide

In the afternoon of 16/02/2024, Juliette was discovered unresponsive in ████████ by a family friend, surrounded by multiple empty packets of medications, and was subsequently confirmed deceased at 13:43. Post-mortem investigations indicated she had died from a fatal overdose. Juliette had been missing since the evening of 14/02/2024 when she left home following difficulties in her personal life and was last seen alive by a friend at around 22:00 on 14/02/2024. Juliette was seen crying on the porch of her friend’s home on Fallowfield Road before heading in the direction of ████████. She had a history of mental health illness since 2010 and had been under the care of both her GP and her local mental health team. At the time of her death, Juliette had been awaiting a follow-up appointment with the mental health team since January 2023 which had been delayed due to staffing shortages, but it is unlikely that her death could have been prevented.

Following a post mortem, the medical cause of death was determined to be:

1a ████████ and ████████ toxicity
1b
1c
II Presence of ████████, ████████, ████████, ████████, ████████ and ████████

1. Following Juliette's death, a Structured Judgement Review ("SJR") was carried out which identified steps that have been taken. However, the SJR confirmed that a review of Rio records was being undertaken of those who have not been seen in over 12 months with actions to be identified, and that clinical stratification of current caseload is ongoing. I understand that a review or audit of this process is being scheduled to take place at some point in October 2024 (date unknown).
2. Upon conclusion of the inquest, I am Functus Officio meaning that my powers cease and I will have no way of checking if the recommended actions have been completed. In the circumstances, where action to be taken is outstanding and when a specific review date has not been scheduled, I am concerned that there is a risk of future deaths occurring.
3. The deadline for a response under this Report should coincide with the Trust's planned review/audit in October, therefore I am hopeful that the Trust will be able to respond swiftly thereafter, and hopefully will be able to confirm that positive action has been taken and whether any further work is necessary.