Fadhia SEGULEH · Prevention of Future Deaths report

On 25th February 2021 I commenced an investigation into the death of Fadhia SEGULEH .The investigation concluded on the 10th August 2021 and the conclusion was one of narrative: Died from the complications of suspension from a ligature.
The medical cause of death was 1a Diffuse Cerebral Oedema and Hypoxic Brain Injury 1b Asphyxia and Cardiac Arrest 1c Self hanging by ligature suspension

Fadhia Seguleh was receiving treatment for anxiety and depression. On 24th February 2021 she was found unresponsive attached to a ligature at her home address West Downs Road.
Conclusion of the Coroner as to the death: Died from the complications of suspension from a ligature.

1. The inquest heard evidence that she was being treated by the NHS Mental Health Trust, GP and through private therapy provided by her employer. As a consequence, the professionals treating her did not have a full picture of disclosures made by her and professionals operated in silos. There was no protocol in place for information sharing between those involved and no policy to guide appropriate steps to obtain information. A query raised with the GP would have enabled a clearer picture of the issues to be held by the private provider. Information sharing would have provided a more rounded understanding of risks.
The operation in silos meant that the treatment plan put in place by the mental health team including medication was not fully understood by the GP and was altered following a consultation between the GP and Fadhia. Information sharing between agencies would have allowed for a more detailed assessment of risk in the situation.

2. As a consequence of Covid all of the assessments of her by her GP in relation to her mental health were done via telephone. Prior to Covid it was likely that they would have been done face to face. It was accepted that assessments of mental health risk and understanding of need was far easier to assess face to face.

3. The inquest heard evidence that she had on a previous occasion been taken to A and E due to concerns that she would take her own life/self-harm. Due to Covid she had to go alone to A and E and was assessed alone without input from her family who were aware of the full picture. The experience of attending alone whilst experiencing mental health issues was deeply stressful for her and meant that she had been unsupported by her family at a time of crisis. In addition, the quality of information available was limited as a result of her being there alone.