Andrea Denise MANN · Prevention of Future Deaths report

On 20 February 2024 I commenced an investigation into the death of Andrea Denise MANN aged 61. The investigation concluded at the end of the inquest on 13 January 2025. The conclusion of the inquest was that:

Upon the 10th February 2024, at her home address, Andrea Denise Mann was discovered by a member of her family, to be hanging from a noose placed around her neck ████████

Mrs Mann was released from her position, and transported by the Ambulance Service to Bradford Royal Infirmary where she was admitted to the Intensive Care Unit. Despite receiving advanced life support the medical condition of Mrs Mann did not improve. Following discussions between attending clinicians and the family of Mrs Mann, a decision was made to withdraw invasive medical care, with Palliative Care then being provided to her.
Sadly, the death of Mrs Mann was certified at the hospital on the 11th February 2024 at 14.44 hours.

Andrea was found by her husband, hanging ████████ Emergency services attended, CPR commenced and she was admitted to hospital. She was admitted to hospital, but sadly the following day she was weaned from the ventilator, as family felt that she would not wish to continue with ICU invasive therapy if she would not be able to return to her previous level of function. She passed away a few hours later.

The findings made by myself at the Inquest include the following;
1) That during the period of her involvement with the Community Mental Health Trust between the period 25/04/2023 and 04/12/2023 the care given to the deceased was limited to 2 appointments only within which she was referred back to her GP for medication adjustment which had been seen to be ineffective, and referral to Psychological therapy sessions which had a waiting period of 6 months despite an earlier private consultation having been proved ineffective,
That the frequent requests of the deceased and her family for a Psychiatric appointment had not been provided to her, with the result that the deceased had to seek a private consultation.
2) That no evidence of any overarching management tool existed to provide scrutiny of the care given to the deceased, or measure the success or efficacy of such care, and as such there were many lost opportunities to provide to the deceased and her family sufficient, consistent, controlled and bespoke care.