Gail Ann Bannister · Prevention of Future Deaths report

On 20/9/17, I commenced an investigation into the death of Gail Ann Bannister then aged 60.
The investigation concluded at the end of the inquest on 8 February 2018.
The conclusion of the inquest was suicide, the medical cause of death being 1a) hanging.

Mrs Bannister had a long history of fluctuating mental health condition. In March 2017, she was noted to suffer a deterioration following the illness and subsequent death of her father. She was seen by her GP and then referred to CARS and onto the HTT service. She was referred back to CARS in early August 2017. A Care Co-ordinator had been appointed on 20 July to facilitate psycho-social services that it was felt Mrs Bannister required and to provide continuity in her care. Her care co-ordinator did not see her between the date of her appointment and Mrs Bannister's death two months later.

(1) The rationale behind discharging Mrs Bannister from the HTT to CARS was that she had been seeing too many different people. It was felt that by concentrating her care in the hands of the community consultant psychiatrist and a Care Co-ordinator, who would arrange the psycho-social services she would benefit from, this would improve her treatment. The fact that the care co-ordinator did not see her frustrated and undermined this approach.
(2) During the inquest I was told that the deceased's husband tried to speak to members of the care team who were based at the Studdart Kennedy centre when a crisis developed. It took him several hours to get through. I was told there is only one phone line and that this is a known and recurring problem.