Sharon Louise Kelly · Prevention of Future Deaths report

On 27 June 2019 I commenced an investigation into the death of Sharon Louise Kelly aged 44 years old. The investigation concluded at the end of the inquest on 12 November2019.
The conclusion of the inquest was
Sharon Louise Kelly killed herself.
The contributing factors were as follows:-
• The timing of the Mental Health Act assessment was inadequate
• Failure to initiate the risk assessment upon arrival at the property by the EEAS
• Widespread insufficient communication between all services. including medical cause of death and short-form conclusion or narrative conclusion summarised).
The medical cause of death was
1a) hanging
11) alcohol and multiple drug overdose

Ms Kelly had a long history of mental health and alcohol problems with frequent suicide attempts. She informed a family member that she would kill herself on the anniversary of her baby son’s death. The ambulance attended her property but did not enter, awaiting police attendance which was delayed. When, eventually the services entered the property Ms Kelly was deceased.

• Whether there is sufficiently clear training at EEAS in relation to (1) identifying relevant flag markers to ensure police attendance at a property where appropriate and 2) communicating relevant information from relevant records to ambulance crews to ensure that dynamic risk assessments take place on the basis of all relevant information (in light of decision making and delays on 27 June 2019)
• Whether lines of communication and the modus operandi between EEAS and Essex Police are sufficiently clear in relation to a potential joint attendance at a property where there is a risk marker (given the delays on 27 June 2019)
• Whether there is sufficient clarity in the training for Essex Police Comms Officers as to the circumstances in which a blue lights response should be mandated (in light of the evidence of Insp ████████ as to the response on 27 June 2019)
• Whether EPUT can review its arrangements for convening an urgent MHS assessment, in conjunction with social services. (in light of the jury’s findings with regard to the MHA assessment in June 2019)