Barbara Caroline Ellis · Prevention of Future Deaths report

On the 24th April2017 I commenced an investigation into the death of Barbara Caroline Ellis. The investigation concluded at the end of the inquest on the 25th January 2018. The conclusion of the inquest was suicide. The medical cause of death was 1A multiple injuries 1B

This 52 year old lady had a significant history of physical and mental health difficulties. Following the death of her husband in 2012 she had really struggled with her loss. From 2014 she began accessing mental health services. Despite receiving support her mental state remained very fragile and she made multiple attempts to take her life. In 2017 she had been reviewed by her Psychiatrist and her GP. April was the anniversary of her husband’s death and her care package was increased to reflect this. On the 4th April she saw her support worker. Mrs Ellis was making future orientated statements and gave no indication that she was planning on taking her life. She also spoke to her daughter on the telephone at approximately 5.30 pm and again no indication was given. At some point during the evening Mrs Ellis made her way to the overbridge located near to Bromserrow Heath between junctions 2 and 3 of the M50. She tied a ligature to the bridge, and jumped off it impacting with the carriageway below and suffered multiple injuries. Mrs Ellis had left suicide notes on her person and at her home address. Her body was discovered by highway workers. She was transferred to the regional trauma centre, and investigations soon revealed the extent of her injuries. Clinicians advised that she was not fit for operative intervention, and brain stem testing was carried out. Mrs Ellis was pronounced deceased at 13.25 hours on the 6th April 2017.

The Cross border issue of care - whether patients can access services adequately when they have a GP in one County, and pay Council tax to another.

In this case Mrs Ellis had a GP in Herefordshire, but paid Council Tax to Gloucestershire. This meant that her healthcare was being provided by Herefordshire Commissioners, and her social care from Gloucestershire Social Services. This result in her being unable to access therapeutic services from either commission.