Joanna Leven · Prevention of Future Deaths report

On 9th April 2020, I opened an inquest into the death of Joanna Leven who was found dead at her home on 26th March 2020, aged 34 years.

A post mortem examination undertaken by Dr ████████, consultant pathologist, determined that Ms. Leven died as a result of asphyxia.

The coronial investigation into her death concluded with the inquest, which was heard before me on 26th – 27th April 2021, resulting in a conclusion that Ms. Leven had died as a consequence of suicide.

Ms. Leven was found dead at her home on 26th March 2020 as a consequence of asphyxia which was self-induced with the intention of bringing about her death. Ms. Leven was under the care of community mental health services having previously been diagnosed with Emotionally Unstable Personality Disorder arising from traumatic experiences in childhood.

As a result of her Personality Disorder, Ms. Leven had frequently self- harmed and/or attempted suicide, often telling others what she had done. A major protective factor in maintaining Ms. Leven's safety was her dog.

In February 2020, Ms. Leven's dog became seriously unwell. This led to a profound deterioration in her mental health. After Ms. Leven's dog was euthanized in March 2020, she cut her groin and took a mixed overdose, resulting in her being taken to hospital. Whilst she received treatment there for her physical health, Ms Leven left hospital before the mental health liaison team could assess her.

Despite the clear deterioration in Ms. Leven's health, the removal of the major protective factor in maintaining her safety and her e-mailing her care coordinator to inform him she intended to complete suicide after leaving hospital, no comprehensive mental health assessment took place.

It is possible the absence of a comprehensive mental health assessment at this point in Ms. Leven's life might have contributed to her death.

1) The court heard evidence that there is no national therapeutic pathway for treatment of Personality Disorders. Whilst the court heard steps are in place to introduce a local pathway for residents of Greater Manchester, it is understood eligibility for and availability of various therapies which may be beneficial to patients diagnosed with a Personality Disorder varies from place to place;

2) Evidence was heard in court to the effect that there are gaps in provision by statutory agencies of counselling and other mental health services specifically tailored for victims of trauma, violence and domestic abuse. In Stockport, specialist services of this nature fall to be provided by a registered charity with only short-term funding in place, a position which is understood to be replicated elsewhere in the country;

3)The court heard evidence that, where a patient attends a Hospital Emergency Department with both physical and mental health needs, it is usually the case that Hospital and Mental Health Liaison staff are working with different computer-based records systems. This creates an obvious risk of information being lost or incompletely conveyed as between different professional groups.