Joy Burgess · Prevention of Future Deaths report

On 25th June 2021, Anna Morris, Assistant Coroner, opened an inquest into the death of Joy Burgess who died on 9th June 2021 aged 56 years. The investigation concluded at the end of the inquest which I heard on 4th February 2022.

A post-mortem examination undertaken by ████████ Consultant Pathologist, determined Ms Burgess died as the result of multiple injuries.

By way of conclusion, I recorded that Ms Burgess died as a consequence of suicide.

Joy Burgess died from multiple injuries sustained as a consequence of ████████.

Ms Burgess had a long history of complex mental health difficulties and had been under the Community Mental Health Team. In addition to being prescribed medication, Ms Burgess was on a lengthy waiting-list to access psychological therapies.

In May 2021, Ms Burgess’s mental health deteriorated with her developing an increasing array of depressive symptoms, anxiety which was providing difficult to manage in the community, and thoughts of self-harm.

She was admitted to hospital as a voluntary patient, but took her own discharge a number of days later. Ms Burgess disclosed to staff that this was because she found the ward environment was busy and extremely noisy. Ms Burgess described being disturbed by the screams of some of the patients, and considered being on the ward was making her feel worse.

Upon leaving the ward, Ms Burgess was followed-up by her Care Co-Ordinator and the Home Treatment Team.

1. The Court heard evidence that the mental health ward environment could be ‘chaotic’ (in the words of one Consultant Psychiatrist) and that resources and demands on inpatient beds were such that staff were not always able to care for patients in a suitable environment. It is a matter of concern that mental health patients are, on occasion, cared for in an environment which is very obviously not conducive to recovery.

2. The Court heard that patients continue to experience lengthy waits if referred for psychological therapies, both locally and nationally. In the Tameside area, the current average wait was thought to be around one year from referral.