Fallon Alphonsine ABBY · Prevention of Future Deaths report

On 19 February 2002, one of my assistant coroners, Heather Williams, commenced an investigation into the death of Fallon Abby, aged 18 years. The investigation concluded at the end of the inquest on 7 August 2017.

I made a determination of suicide, when Fallon jumped from the balcony of her sixth floor bedroom at around 10.45pm on Saturday, 18 February 2017, while two members of the ambulance service were attempting to persuade her to go to hospital for treatment.

Fallon had attended the emergency unit at the Royal London Hospital a week before her death following an intentional overdose, then re-presented with alcohol toxicity. She was admitted to Roman Ward of Mile End Hospital because she was thought to be at high risk of suicide. She was discharged to the care of the home treatment team on Thursday, 16 February 2017.

I heard at inquest that no member of the team on Roman Ward contacted Fallon’s social worker. There was no protocol for this.

If they had sought a collateral history from the social worker, they would have discovered that Fallon’s mum was not dead as Fallon had told them, but was alive and living in a hostel. The social worker had been rung by a nurse at the Royal London Hospital, but she was waiting to be invited to a ward round at Mile End Hospital and such invitation was never made.

It seems unlikely that proper discussion with the social worker would have changed the outcome for Fallon, but it would have meant that valuable information would have been shared, and it would have meant that Fallon would have had the benefit of her social worker on hand upon discharge. This might be very important for another patient.