Mollie Rose Stansfield · Prevention of Future Deaths report

On 12th July 2019 I commenced an investigation into the death of Mollie Rose Stansfield, age 22 years. The investigation concluded at the end of the inquest on 9th December 2022. The conclusion of the inquest was:

NARRATIVE - Mollie Rose Stansfield was born on 6th January 1997 in Hull and died on 10th July 2019 on Princes Quay, ████████ ████████, Hull after falling ████████. She suffered multiple injuries as a result of this fall which resulted in her rapid death. She had an underlying diagnosis of Emotionally Unstable Personality Disorder, as well as a history of drug and alcohol abuse. She was admitted to the Avondale Unit on 27th June 2019 as an informal patient, after being transferred there following presentation to Hull Royal Infirmary with a self-inflicted neck wound which was appropriately treated. Whilst there she absconded and purchased a number of ████████ tablets, which she took, but did not tell the nursing staff who discovered it later that day. She was transferred back to Hull Royal Infirmary and treated for this overdose. Upon her return to the Avondale unit she became physically unwell and was sent back to Hull Royal Infirmary for investigation of what was thought to be a cardiorespiratory problem. This was refuted and it is likely that her physical symptoms were due to the systemic toxic effects of cocaine. She absconded from the ward on a number of other occasions and sourced ████████ whilst absent, which she took. She suffered a fit as a result of taking ████████ but recovered. A Section 5.2 Mental Health Act order was put in place, but was probably not valid at material times. She was discharged to step down accommodation following being declared medically fit and following assessment by a psychiatrist. She was evicted from the step down accommodation on 10th July following an alteration the previous evening, and

went to a high rise block of flats with the intention of jumping off. Her friend however intervened, called the police who attended the flats and removed her to a place of safety, Miranda House, under Section 136 of the Mental Health Act 1983. Following a mental health assessment at 13:00 on 10th July she was found neither to be psychotic nor intoxicated with ████████. She subsequently took ████████ following her discharge and went to Princes Quay and fell to her death ████████ ████████. The effects of ████████ may have clouded her judgment but equally the text message exchanges prior to her assessment at the Section 136 suite and after her release suggested that she intended to take her own life.

See section 3

There was a failure at Hull Royal Infirmary to understand the process of implementing Section 5(2) of the Mental Health act 1983 [MHA] (Doctors Holding Power) as well as general uncertainty about its significance and effect. Mollie absconded from the ward whilst apparently under this section. The paperwork for the implementation of this section of the MHA 1983 was in fact not properly completed and hence invalid. Whilst the Hull & East Yorkshire NHS Trust has taken steps to educate doctors about this power, these were only local measures and I believe that all doctors working in England and Wales should be aware of section 5(2) and nurses of their equivalent power pursuant to section 5(4) of the MHA 1983 and that appropriate awareness and training should be given.