Caroline Antoinette Scott · Prevention of Future Deaths report

On 02/06/2017 I commenced an investigation into the death of Caroline Antoinette Scott, aged 52. The investigation concluded at the end of the inquest on 17th May 2018. The conclusion of the inquest was a narrative Conclusion:
The deceased suffered from depression and had thoughts of suicide immediately prior to her death and sought medical advice. It was recognised that she was in crisis but there was a failure to carry out a mental health assessment that resulted in a lost opportunity to refer her for treatment. She was found hanging at her home on 30th May 2017. She was taken by ambulance to Milton Keynes University Hospital where she died on 2nd June 2017.

The cause of death was:
1 (a) Multi Organ Failure
1 (b) Hypoxic Brain Injury following Hanging
2. Depression

The deceased suffered a head injury in 2009, leading to depression for approximately 10 years. She had made previous attempts at suicide and was considered high risk. On 30th May 2017, she was found by family hanging in the garage. An ambulance was called and she was cut down and CPR commenced. She was transferred to Milton Keynes Hospital where she was treated until she passed away on 2nd June 2017. In the weeks leading up to her death, she had contact with her GP, the accident and emergency department and the out of hours service.

(1) That the provision of out of hours emergency service for mental health emergencies is inadequate
(2) That the policy for emergency referrals is not fully understood by all medical services in Milton Keynes