Amanda Jane Vickers · Prevention of Future Deaths report

On 28th August 2013 I commenced an investigation into the death of Amanda Jane Vickers, aged 47 years. The investigation concluded at the end of the inquest on 27th January 2014. The conclusion of the inquest was cause of death 1(a) Hanging. Conclusion: Took her own life whilst the balance of her mind was disturbed.

The deceased had a long history of depression and suicidal ideation. Over the days before her death she had daily contact with her mental health nurse. She was to be referred to a residential crisis home, but no room was available immediately. On the evening of the 22nd August 2013 the deceased was found hanging by the neck from a fabric ligature attached to a roof beam at her home address.

This lady died whilst awaiting a place at 81 Lowther Street Crisis Home. She had been there before and found it therapeutic. No space was available, and no date when one might arise was known. She died whilst waiting for admission. The evidence was that this 6-bedded unit is the only one of its type in the whole county. It is understood that the CCG is responsible for commissioning such facilities. On the balance of probability an admission would have made a difference in this case. A review of the facilities available is suggested with a view to the provision of a greater number of beds for patients such as the deceased.