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Investigation and inquest
On the15th of October 2018 I commenced an investigation into the death of Hannah Elizabeth Browning (DOB 18.4.96 DOD 12.10.18) The investigation concluded at the end of the inquest on the 12th of April 2021. The conclusion of the inquest was a narrative in the following terms (and was formulated to include the circumstances by which she came to her death as Article 2 was engaged.)
“Hannah Elizabeth Browning was being treated for her mental health issues from mid-December 2017 until her death on the 12th of October 2018. She had a diagnosed condition of Emotionally Unstable Personality Disorder, likely triggered by her being raped at the age of thirteen and exacerbated by chronic pain from a physical problem. During the period of her treatment she was known to have self-harmed and to have had suicidal thoughts.
On the 10th of October 2018 she expressed to persons engaged in her care and treatment that it was her intention to end her life that day, yet, despite this, inadequate arrangements were made to protect her and insufficient efforts were made to keep her safe.
On that same date, in the general location where she had been raped as a child, she placed a ligature around her neck and hanged herself with the result that she sustained a hypoxic brain injury which resulted in her death at the Wrexham Maelor Hospital on the 12th of October 2018”
Circumstances of the death
The circumstances of Hannah’s death are detailed in the above narrative conclusion.
The published report provides this section by reference to another part of the report.
Coroner’s concerns
That despite giving an indication of an immediate and fixed plan to harm herself, which she then acted upon, the Mental Health Services made inadequate arrangements to protect her and made no attempt to contact her to either seek to ensure her safety or to advise her of the intention to review her case at an MDT five days later and to reinforce the interim options available to her in crisis.
Despite hearing evidence at the inquest of the steps taken by BCUHB and WCBC (who act in partnership for the provision of Mental Health Services) to improve the service, I was not provided with any assurances as to measures which had or could be taken to ensure that every possible effort is made to contact a person under their care, who has communicated a credible indication of an immediate risk of harm to themselves.
