Susan Mary Regan · Prevention of Future Deaths report

On the 5th August 2020, The Coroner opened an Inquest into the death of Susan Mary Regan. The investigation concluded at the end of an inquest on the 27th April 2022. The conclusion of the inquest was a narrative form conclusion of suicide contributed to by a failure by Mental Health Services to recognise her deteriorating mental health and the increased risk she presented and to take effective steps to reduce the risk.

The cause of death was 1a) Hanging

Susan Regan was a 61 year old lady who had no relevant past mental health medical history. She was a long serving, well thought of, member of staff at Marks and Spencer. Her husband ████████ died in 2017 and this did understandably affect her but save for some minor characteristic anxiety she had no recorded mental health issues. Following furlough from her role at Marks and Spencer, she began to deteriorate in terms of her mental health and her general wellbeing. She became malnourished and dehydrated combined with increasingly disturbed behaviour consistent with anxiety, arguably displaying potential psychotic tendencies and evidence of self-harm. This resulted in a consultation with the G.P. on 12th June 2020, involvement of The Mental Health Access Team on 5th June 2020, the appointment of The Home Based Treatment Team followed by an admission to Stepping Hill Hospital in respect of the poor state of her mental and physical health, on 11th June 2020, followed by an assessment under the Mental Health Act on 14th June 2020 resulting in admission to a Mental Health Ward under section 2 of The Mental Health Act. Following improvement in her condition, the section was rescinded on 23rd June 2020 and Mrs Regan was discharged home with continuing support from The Home Based Treatment Team. There were ongoing symptoms and matters reached a head on 23rd July 2020 when Mrs Regan was reported to be at the end of her drive, screaming.

Advice was sought and a visit planned for 24th July 2020 at which Mrs Regan was described as anxious, very agitated and rubbing her hands and face. Throughout a series of assessments over the months Mrs Regan would either deny suicidal ideation or avoiding answering the questions. She was known to not want to be hospitalised but her sons remained concerned that she be kept safe. Crucially, they were not consulted on this point 24th July 2020 contrary to the specific instructions of a Doctor when she was consulted on 24th July 2020. There was a failure to have a discussion with Mrs Regan's sons about their opinions on hospitalisation and the risks of not doing so. There was a further failure to record any reference to hospitalisation in their notes following the visit on the morning of 24th July 2020. Mrs Regan's dosage of diazepam was doubled and there appeared to be some improvement in her level of anxiety. A planned visit took place on the morning of 25th July 2020. Later that afternoon Mrs Regan took her own life by ████████
████████ as a ligature, around the neck, in ████████ her home address.

1) During the course of the Inquest evidence emerged that the clinical guidance of a Doctor required the Home Treatment Team to speak to Mrs Regan's sons to explore whether they feel she needed to be admitted on an inpatient psychiatric unit. Admission to also be considered if Ms Regan would continue to show non-compliance on her medications. Such an enquiry was not undertaken.

2) It was also confirmed in evidence that there was a failure to properly record a plan and properly communicate such a plan with Mrs Regan’s sons.