Investigation and inquest
On 26/04/2021 I commenced an investigation into the death of Hannah Grace Beardshaw, aged 25. The investigation concluded at the end of the inquest on 04/04/2022. The conclusion of the inquest was suicide.
Circumstances of the death
The deceased was formally pronounced dead at her home address of ████████ ████████ Wigan on the 20ᵗʰ April 2021. The deceased had a complicated medical history and had struggled with her mental health for many years, having previously attempted to take her own life. In the period leading up to her death, she struggled to cope with life and researched methods of taking her own life on the 19ᵗʰ April 2021. On the 20ᵗʰ April 2021 at 11.47am, the deceased contacted a friend requesting that her cat was looked after. She was crying and left a detailed note of intent saying goodbye to her loved ones. Welfare concerns were raised to Greater Manchester Police (GMP) at 12.30pm and the incident generated a 20 minute allocation and 1 hour vehicle response. An ambulance was requested to the incident at 12.45pm and arrived at scene at 2.10pm. At 2.26pm, Greater Manchester Police were contacted by ambulance control requesting police assistance to gain access to the premises. At 3.14pm, 3.59pm and 4.14pm, ambulance control continued to chase Greater Manchester Police for an estimated time of arrival. Greater Manchester Police officers arrived on scene at 4.47pm and a method of entry officer arrived on scene at 5.17pm to gain access to the property. The deceased was discovered hanging having used a ████████. A paramedic was deployed and diagnosed death at 5.36pm on the same day.
Coroner’s concerns
The IOPC highlighted a number of learning recommendations on how GMP handled the incident which to date have not been implemented:
• A delay in escalating the incident, resulting in almost a 4 hour delay to respond to the incident.
• A failure to make method of entry kits more readily available to those trained in their use.
• Improvement in document management