Jacqueline Williams · Prevention of Future Deaths report

On the 28th January 2018 I commenced an investigation onto the death of Jacqueline Williams aged 42. The investigation concluded at the end of the Inquest which was concluded on the 28th October 2015. The conclusion of the Inquest was that Jacqueline Williams had committed suicide.

On the evening of Monday 26th January 2015 Jacqueline Williams was conveyed by ambulance to the Royal Blackburn Hospital where she was triaged and assessed to be at moderate risk of self-harm. A decision was made that she should be referred directly to the Mental Health Liaison Team. Due to a breakdown in communication between the triage nurse and the Mental Health Liaison nurse no actual referral was accepted by the Mental Health Liaison Team. Having been placed in a cubicle within the emergency department at the Royal Blackburn Hospital Jacqueline Williams hanged herself from the central observation light using the electrical cord tied around her neck.

That the process of referral to the Mental Health Liaison Team was subject to human error and that the systems in place failed to provide for such mistakes to be easily identified and rectified. In particular there was no opportunity for staff in the emergency department to see confirmation that a referral had been accepted, the time of that referral and the expected time when a mental health assessment would take place. Likewise the Mental Health Liaison Team did not have a process that whereby they were able to identify those patients that the staff in the emergency department believed had been referred and were awaiting assessment.