Finnulla Catherine MARTIN · Prevention of Future Deaths report

On 19 November 2014, I commenced an investigation into the death of Finnulla Catherine Martin, aged 35 years. The investigation concluded at the end of the inquest today. I made a narrative determination, which I attach to this letter.

Ms Martin took her own life by jumping from the sixth floor balcony of her home, less than an hour after she had been discharged from the Whittington Hospital where she had undergone a mental health assessment.

Camden and Islington Trust

1. It seemed from the evidence I heard that the Camden and Islington Trust psychiatry liaison team (doctor and nurse) operating at Whittington Hospital on the night of 15 November 2015, were not wholly clear about the protocols for receipt of information from police officers bringing patients into hospital on a voluntary basis.

2. The team then saw a patient without waiting to obtain the triage record created by Whittington Hospital Trust staff.

3. The doctor did not ask Ms Martin about thoughts of suicide within the context of her earlier declaration that she would die that night.

4. He did not ask her about any thoughts of harming another person, regardless of the fact he was not aware that she had threatened this.

5. He did not address his mind to what had led up to the police being called for Ms Martin, nor who had called them.

6. Neither doctor nor nurse obtained a collateral history of events from a family member before concluding their interview with Ms Martin.

7. When they obtained this afterwards and then realised that Ms Martin had left the hospital, they contacted the police but did not characterise this as an emergency.

8. The crisis team did not pass on information received from Ms Martin’s sister to the psychiatry liaison team with a sufficient degree of urgency to ensure that this was taken into consideration before the interview with Ms Martin was concluded.

Whittington Hospital Trust

1. There seemed to be some degree of confusion surrounding the voluntary attendance of a patient with mental health needs accompanied by the police, that suggests a multi agency discussion and agreement would be beneficial.

2. I was told at inquest by Camden & Islington that the Whittington had been unable to locate the Whittington triage record of Ms Martin’s attendance, and I did not discover any record of the call made by Ms Martin’s sister to the emergency department that night.

Metropolitan Police Service

1. The police call handler who spoke to Ms Martin did not record that she said: “I need to jump a balcony”. This was important information.

2. As I have indicated above, the confusion surrounding voluntary attendance of a patient with mental health needs accompanied by the police, suggests a multi agency discussion and agreement would be beneficial.