Jacqueline Anne Cobain · Prevention of Future Deaths report

On the 16 September 2021 an investigation into the death of Jacqueline Anne Cobain commenced, aged 60 years. The investigation concluded at the end of the final day of the inquest on 15 March 2024. The conclusion of the inquest was a short form conclusion of suicide.

Jacqueline Anne Cobain had a past medical history of anxiety and depression, as well as alcohol dependence. She was consulting with her GP in relation to these issues and was taking antidepressants. She had also contacted mental health services, although she had cancelled the scheduled appointment and the rescheduled appointment was not until 16 September 2021, however she had submitted her responses to a questionnaire shortly after cancelling her appointment which had included some concerning responses. This questionnaire was not reviewed upon receipt. She had taken an overdose some years before at a time of great stress in her work life and her family believed this was not an attempt to take her life, but rather a consequence of stress, desperation of her work situation and insomnia. During the afternoon of 11 September 2021, she deliberately jumped in front of moving train at Vauxhall London Underground station, London. Her family indicated that she seemed stable, and they were less concerned about her than they had been for some time. She suffered multiple injuries and died at the scene.

1. When Mrs Cobain cancelled her appointment scheduled for Monday 6 September 2021 by email on Saturday 4 September 2021, the system nevertheless generated an automatic questionnaire which is normally is sent 24 hours prior to a scheduled assessment appointment. The system had not recognised that Mrs Cobain had cancelled her appointment. She completed the questionnaire.
2. Mrs Cobain’s responses to the questionnaire contained what were accepted to be concerning responses.
3. Due to the cancellation the questionnaire was not reviewed by a clinician until after Mrs Cobain’s sad death.
4. Changes have been made to the protocols around cancellation, and language has been added to the assessment template.
5. However, there is no system or protocol to alert a clinician to review concerning responses and to consider appropriate next steps, where (outside the usual protocol and time frame of submission and review within 24 hours of the assessment appointment) the patient has completed the questionnaire, and for whatever reason, the assessment appointment with the clinician is not for a period of several days/weeks as was the case in Mrs Cobain’s case.