Name not published · Prevention of Future Deaths report

An inquest into the death of ████████ was opened on 6th December 2017, resumed on the 12th October 2020 and concluded on the 14th October 2020. I concluded with a narrative conclusion that:

████████ died on the 29th November 2017 at ████████. She had tied a ligature around her neck and died by hanging. She had drunk considerable amounts of alcohol and taken cocaine. It is not possible to determine whether she intended to kill herself.

I concluded that the medical cause of death was:

1a. Hanging
.

████████ died at her home address having consumed a considerable quantity of alcohol and cocaine. She tied a ligature around her neck and died by hanging. It was not clear if this was a cry for attention or help and whether she thought she might be found in time.

The evidence showed that:

1. ████████was being treated for depression by her general practitioner. She was prescribed anti-depressant medication. She had last been reviewed in February 2017. She was not open to secondary mental health provision.
2. ████████ was the subject of a MARAC referral organised by the Surrey Police on the 14th June 2017 in respect of allegations of domestic violence and coercive control which ████████ made relating to her partner.
3. ████████ general practitioner was not invited to contribute to the MARAC meetings held in July and August 2017. General Practitioners are not routinely invited to MARAC meetings.
4. The risks and the planned safeguarding measures identified by the MARAC were not communicated to the general practitioner.
5. The general practitioner responsible for treating ████████ mental health was not made aware of the allegations of domestic abuse and coercion that ████████ had made.
6. ████████ children were removed from her care in ████████ and she was then involved in care proceedings. Her general practitioner was not made aware of this although it would have been a further significant stressor so far as her mental health was concerned.