Zahra Sharif Mohamed · Prevention of Future Deaths report

On 19 October 2022, I commenced an investigation into the death of Zahra Sharif Mohamed aged 53 years. The investigation concluded at the end of the inquest on 16 August 2024. The jury returned a suicide conclusion supported by a narrative, which I attach.

I drafted this report in early October 2024. However, it was not issued at that time owing to an IT error.

Mrs Mohamed developed mental health problems after being diagnosed with breast cancer in 2014. In early 2022, she was suicidal and was detained under Section 2 of the Mental Health Act in March 2022. She was released from hospital the following month and went to visit family abroad. On returning to the UK in July 2022, she was irrational and paranoid and her children’s social worker referred her back to mental health services. Mrs Mohamed was again detained under section 2 MHA on 21 September 2022. Mrs Mohamed’s full mental health history was not easily available due to a cyber-attack. On 30 September 2022 Mrs Mohamed was sent on home leave for a week pursuant to Section 17 Mental Health Act. On the evening of 3 October 2022, Mrs Mohamed made a succession of distressed telephone calls to her children’s social worker. On 4 October, she sent text messages to her children’s social worker threatening to kill her children and expressing the need to return to hospital. Attempts were made to persuade Mrs Mohamed to return to hospital voluntarily but she refused. Over the following days, she expressed suicidal thoughts and threatened to jump from the balcony outside her 5ᵗʰ floor flat to professionals. The community mental health team was of the view that Mrs Mohamed needed to return to hospital. However, the ward did not apply for a warrant under s135(2) Mental Health Act to return her to hospital and instead asked the community mental health team to persuade her to return to hospital voluntarily. On 12 October 2022, Mrs Mohamed jumped from the balcony. Her death was confirmed at the scene. The medical cause of her death was 1a) Multiple severe traumatic injuries 2) excessive Mirtazapine intake. At the time of her death, the ward had not applied for a warrant to return her to hospital under s135(2) Mental Health Act.

(1) It was accepted that a s135(2) warrant should have been applied for on 4 October 2022. However, if an application had been submitted to the magistrates’ court that day, it is unlikely that the warrant would have been executed before Mrs Mohamed’s death. In evidence, I was informed by a number of mental health professionals that the time taken for a s135(2) warrant to be obtained from the magistrates’ court and executed by the police was in the region of 2 weeks.
(2) The process for obtaining a warrant is that an application has to be made for a video hearing at either Uxbridge or Westminster Magistrates’ Courts. It could take several days for a hearing to be arranged as the courts consider applications from all 32 London Boroughs. Once the Magistrates issued a warrant, an appointment would then be arranged for the police to execute the warrant.
(3) I was informed that a 2-week timescale for obtaining s135(2) warrants was still the case in the summer of 2024.
(4) I also heard evidence that the mental health team could attend Highbury Corner Magistrates’ Court in person to apply for a warrant in urgent cases but that they were actively discouraged from using this process by the court.
(5) The court heard that the process and timescale for issuing and executing warrants had led to the hospital team adopting a practice of asking the community team to encourage a patient to return to hospital voluntarily before making an application for a warrant.
(6) There is an ongoing risk that patients will harm themselves or others in the period before the warrant can be executed. This includes a risk of fatal harm.