Jane Diane Livingston · Prevention of Future Deaths report

On the 24th December 2018 I commenced an investigation into the death of Jane Diane Livingston. The investigation concluded at the end of the inquest on the 30th September 2019.

The medical cause of death
1a pressure of the neck consistent with hanging

The conclusion of the inquest as to how Ms Livingston came to her death is suicide and is as follows:-

The deceased was pronounced dead on the 23rd of December 2018 at the multi story car park on Trawler Road, Swansea. The deceased died from pressure of the neck consistent with hanging. The deceased had taken her own life. The deceased had suffered with anxiety and depression for twenty years which deteriorated from November 2018 onwards. The deceased was referred for a Gateway Assessment which placed her under the care of the Assessment and Home Treatment Team on the 21/22 December 2018. The assessment was appropriate and there were no grounds to detain the deceased under the Mental Health Act 1983.

The deceased was Jane Diane Livingston and she was pronounced dead on the 23rd of December 2019 at the multi story car park on Trawler Road, Swansea. The cause of death was suicide after she was found hanging at the above location.

Jane was receiving treatment for mental illness by the Community Mental Health Team (CMHT) and the Assessment and Home Treatment Team (AHTT). Jane was diagnosed as having depression and anxiety. Her condition was managed by her General Practitioner for twenty years until her condition deteriorated in November 2018

Jane was reviewed by a Psychiatrist on the 8th of November and was given a treatment plan recommending treatment in the Community. This plan was complied with and Jane was discharged from the crisis team on the 26th of November 2018 however remained under the care of CMHT. The evidence of the Community Psychiatric Nurse (CPN) was that on the 14th of December 2018 Jane had been reviewed by CMHT, who referred her to Cefn Coed Hospital for a gateway assessment that was conducted on the same day to determine which pathway her treatment would follow. During that review Jane stated that she wanted to be referred as a voluntary patient at hospital since if she was left at home she would contemplate suicide. During the gateway assessment this was not mentioned and the CPN conducting the gateway assessment was unable to access the CMHT review as it had not been uploaded onto the case management system. The deceased went on to have further assessments in which the CMHT review subsequently became available on the case management system.

During the course of the inquest it was apparent that the deceased’s wishes for hospital treatment and the reasons behind the same were not available to the gateway assessors on the 14th of December 2018. In this case the deceased underwent further assessments therefore the effects of this situation were reduced. I am concerned however that in other cases this could result in situations where a patient’s own concerns are not addressed or taken into consideration when conducting an assessment that could lead to an assessment based on incomplete information and result in another patient taking their own life.

1. The gateway assessors did not have full access to the notes relating to the review and subsequent concerns that triggered the gateway assessment. This may result in the assessors not obtaining the full picture when assessing a patient and making a treatment plan based on incomplete information.