Lesley Ann Armstrong · Prevention of Future Deaths report

On the 19th November 2018 I concluded an Inquest into the death of Lesley Ann Armstrong, who died at her home address on the 20th July 2016. I recorded my conclusion that Mrs Armstrong had taken her own life, and that the medical cause of her death was due to 1a) hanging.

While working as a care assistant at the Riverside House Care Home, Morpeth operated by Akari Care Limited, Mrs Armstrong had been interviewed by her employers regarding injuries sustained by a resident at the Home, and was subsequently being investigated by Northumbria Police for a possible assault under Section 47 of the Offences Against the Person Act 1861. If that allegation was not proved, Mrs Armstrong and or her colleagues might then have been investigated for an offence of neglect or lack of care, under Provisions of the Care Act 2014, as a separate investigation by the Local Safeguarding Adults Board.

On 21st April 2016 Mrs Armstrong was suspended from work as a result of the allegations described above and was required to attend Bedlington Police Station on 30th April 2016 as a voluntary attender for interview under Police caution.

On 7th June 2016, a decision had been taken by Northumbria Police Officers investigating the case to discontinue enquiries for the possible offence under Section 47 of the Offences Against the Person Act 1861. This was finalised as being - no crime detected due to evidential difficulties. Mrs Armstrong was not informed of this decision as she should have been, and consequently believed herself still to be under suspicion for a crime of assault.

On 20th July 2016 Lesley Armstrong’s husband John left their home to go shopping, and when he returned home around 13.45 hours, he found his wife Lesley with no apparent signs of life, as a result of hanging. A note from Lesley Armstrong was found, expressing an intention of taking her life, and in the same note, swearing that she was innocent of the accusations against her.

During the attendance by Police Officers following Mrs Armstrong’s death at her home on 20th July 2016, it was recognised by one of the Officers that the investigation into the suspected assault had been discontinued several weeks earlier, and that this was not known to Mrs Armstrong.

It is recognised that employers have a duty of care to their employees to investigate allegations against them promptly and keep them reasonably informed about the progress of investigation of misconduct. On this occasion the employers Akari Care Limited could not properly inform Mrs Armstrong about the status of their investigation because they were not formally told when the Section 47 investigation by Northumbria Police had been discontinued. Northumbria Police acknowledged at the Inquest that there were procedural errors by two of their Officers, that the procedures themselves required improvement and that they had taken steps to address these. It was not clear that any practical steps had been taken to improve communication with the Local Safeguarding Adults Board or the owners of the Care Home both of whom needed to know when the Police investigations were completed so that the Safeguarding Board could if necessary progress an investigation under the Care Act 2014, and the Care Home could keep Mrs Armstrong informed about progress and her employment position. That lack of information or progress caused Mrs Armstrong to believe she was still under suspicion for an offence of assault.

It is not a matter for the Senior Coroner to attribute blame or to specify how procedures between Northumbria Police and Northumberland Adult Safeguarding Committee should be modified or improved, which is a matter for them to consider and organise. The Senior Coroner does not approach the question as an expert, and his role is to draw to the relevant parties’ attention the concern which has arisen from the circumstances disclosed by the evidence at the Inquest, leaving them to address that concern by taking steps to avoid circumstances which could lead to further deaths in the future.