Sapphire Kathleen BERNARD · Prevention of Future Deaths report

On 13 November 2023 I commenced an investigation into the death of Sapphire Kathleen BERNARD aged 24. The investigation concluded at the end of the inquest on 13 January 2025. The conclusion of the Jury was that:

Sapphire died on 30th October 2023 at East Surrey Hospital as a result of asphyxiation by self-tied ligature occurring at Langley Green hospital on 24th October 2023.

The Narrative Conclusion of the Jury was: “Misadventure. The death was contributed to by vulnerabilities within the risk assessment and observation requirements used to manage admissions into Langley Green hospital”.

Following a deterioration in her Mental Health Sapphire was taken to the Accident and Emergency Department at the Conquest Hospital by Police on 2nd October 2023. She had been detained under section 136 Mental Health Act 1983.

Whilst at the Hospital she underwent a formal Mental Health Assessment following which she was detained under Section 3 Mental Health Act. Sapphire was then nursed in A&E for a further 19 days awaiting a psychiatric bed. During this time there was no suitable psychiatric bed available for Sapphire. She continued to be nursed under 2:1 observations during this period. During this time she continued to self ligature.

On 24th October 2024 Sapphire was eventually found a bed at Langley Green Hosptial. Within hours of being admitted to Langley Green hospital she self tied a ligature whilst being nursed on intermittent observations. She was taken to East Surrey hospital but sadly died a few days later on 30th October 2023.

Her cause of death was:-
1 (a) Hypoxic Ischaemic Encephalopathy
1(b) Asphyxiation by ligature
2. Mental health disorders including emotional unstable personality disorder and autistic spectrum disorder

1. The lack of inpatient beds leading to the unacceptable wait time in A&E for those suffering with their mental health who are awaiting a psychiatric beds.
2. In Sapphire’s case a bed was not found for her within a 19-day period.
3. The unsuitability of the environment of A&E as a holding place for those in need of a mental health bed.
4. The evidence was that the environment in A&E as a holding place is not conducive for those suffering with Autism and/or who are neurodiverse. The environment in A&E can exacerbate and cause further deterioration in their mental health
5. This is a second Inquest that I have heard where a death occurred following a lengthy wait in A&E for a psychiatric bed. In both cases the patients were transgender and had a diagnosis of autistic spectrum disorder.