Colette Denise Vivienne Jean DUNN · Prevention of Future Deaths report

On 23/01/2018 I commenced an investigation into the death of Colette Denise Vivienne Jean DUNN aged 50. The investigation concluded at the end of the inquest on 19th October 2018. The conclusion of the inquest was:

Colette Dunn died from Suicide. She was discharged from Milton Keynes University Hospital by the Mental Health Liaison Team at 14.10 on 22nd January 2018. She had been taken to the hospital by ambulance accompanied by police officers who remained with her throughout because she was threatening to kill herself. She did not have a formal Mental Health Act Assessment prior to discharge and this resulted in a lost opportunity to detain her formally. She, later that afternoon, doused herself with petrol and set fire to herself sustaining severe burns. She died at 05.14 on 23rd January 2018.

See above

1. During the course of the evidence it was clear that prior to discharge from the hospital a full Mental Health Act assessment by a psychiatrist should have been carried out before the decision was taken to discharge Ms Dunn, particularly as the police officers were expressing their concerns to the staff that Ms Dunn had indicated that once she had left the hospital it was her intention to kill herself and indicated that she would tell the staff what they wanted to hear in order to secure her discharge.
2. That there needs to be a clear and agreed protocol between the police, the hospital and the CNWL NHS trust as to how the discharge of patients brought in for assessment is going to be dealt with.
3. There does not appear to be any facility within Milton Keynes for dealing effectively with patients suffering a mental health crisis to ensure they are brought to the hospital for assessment and treatment.