Louise Elizabeth Amy Crane · Prevention of Future Deaths report

On 20 September 2024, an investigation was commenced into the death of Louise Elizabeth Amy Crane, aged 39 years at the time of her death. The investigation concluded at the end of an inquest heard by me between 2 June and 10 June 2025.

The inquest concluded with a short-form conclusion of suicide. The medical cause of death was:

1a ligature compression to the neck

Louise Crane had an established diagnosis of Emotionally Unstable Personality Disorder (EUPD). She also had diagnoses of depression and psychosis (in the context of drug use). Ms Crane first came into contact with mental health services in 2012, since then she had been treated in the community, in voluntary in-patient settings, and while detained under the Mental Health Act.

Ms Crane was admitted to hospital for emergency treatment in relation to her physical health on 2 May 2024, following an attempt to end her life. Once medically fit for discharge, Ms Crane was admitted to an in-patient psychiatric ward at Highgate Mental Health Centre (North London NHS Foundation Trust), under section 2 of the Mental Health Act. This detention commenced on 4 June 2024.

Following Ms Crane’s initial admission to Highgate Mental Health Centre, she was transferred to a psychiatric intensive care unit (Ruby Ward) on 5 July 2024. Ms Crane remained on Ruby Ward until she was stepped down to an acute mental health ward (Topaz Ward) on 5 September 2024.

On 19 September 2024, when Ms Crane remained detained under section 3 of the Mental Health Act, she was found in her room suspended by a dressing gown cord used as a ligature.

The jury’s findings as to how, when, where and in what circumstances Ms Crane came by her death were, as follows:

“Louise Crane died in Highgate Mental Health Centre on 19 September 2024 from a ligature compression to the neck. Factors contributing to Louise’s death were a chronic high risk of suicide linked to Emotionally Unstable Personality Disorder, in combination with unsatisfactory information sharing and recording, and inadequate risk management, staffing and levels of care and treatment during Louise’s time on Topaz Ward.”

1) Evidence from a senior member of North London NHS Trust’s clinical leadership team revealed that there is a lack of a nationwide policy / approach to anti-ligature measures in mental health settings.