Dorota Agnieszka Kijowska · Prevention of Future Deaths report

On 15 March 2016, I reopened the inquest touching upon the death of Dorota Agnieszka Kijowska. I sat with a jury and on 17 March the jury recorded the following conclusions:-

On 23 March 2015, at approximately 16.10pm Dorota Agnieszka Kijowska was found hanging by a scarf from an unspaced loft hatch in a toilet cubicle at Gosfield ward the Lakes Colchester. Resuscitation attempts were unsuccessful and she was pronounced dead at 17.10pm.
Dorota Agnieszka Kijowska killed herself.
Based on the evidence provided, the jury have concluded that there was a failure to provide a safe environment at the unit and this, in conjunction with ineffective communication, more than minimally contributed to her death.

Please see jury’s findings above.

She had been an informal patient at the Lakes Mental Health Unit from 10 March 2015 and she returned from weekend leave at 8am on Monday 23 March 2015. At a review held that day, Dorota expressed threats to harm herself and the plan to give her a further period of home leave appears to have been changed. This was not relayed effectively to Dorota who was found hanging later in the afternoon.

The outcome of the review meeting was not signed off in writing by those in attendance (Consultant psychiatrist, middle grade doctor, review nurse) and clearly communicated to Dorota