Melanie Ellen Lowe · Prevention of Future Deaths report

On 2 March 2016 I commenced an investigation into the death of Melanie Ellen Lowe. The investigation concluded at the end of the inquest on 9 November 2016. The conclusion of the inquest was that Melanie Ellen Lowe killed herself. The jury added a narrative conclusion – Melanie’s risk of self harm/suicide was not properly and adequately assessed and reviewed. Adequate and appropriate precautions were not taken to manage her risk of self harm/suicide

Melanie Lowe, a 41 year old lady had suffered from somatization disorder over a long period of time and was sectioned under s2 MHA in the Derwent Centre Harlow. On the morning of 2 March she was found unresponsive in her room and she was found to have a wad of tissues obstructing her airway. She died in Princess Alexandra Hospital Harlow later that day. Both the trust’s own Serious Incident Investigation report and the independent psychiatric report provided by an independent psychiatrist instructed by the court were highly critical of the care provided to Melanie in the time leading up to her death

(1) The trust's action plan is very basic, lacking specific detail. Some elements are blank and there is an absence of supporting evidence. A far more rigorous action plan is required in an effort to prevent future deaths such as Melanie's.