Emma Jane SIMKIN · Prevention of Future Deaths report

On 01 March 2021 I commenced an investigation into the death of Emma Jane SIMKIN aged 24. The investigation concluded at the end of the inquest on 11 October 2022. The conclusion of the inquest was that:

The deceased died on 20th February 2021 at Railway Lineside, Spitalgate Hill, Grantham by standing in front of a freight train and receiving non-survivable injuries.

Incident was initially referred to the Coroner by way of EMAS Diagnosis of Death form then later by BTP Police. ████████
This matter relates to the death of a 24 old female found on the railway line near Grantham having been struck by a freight train.
Deceased was single having never married nor had children. She is survived by her parents and sister from whom she had been estranged for 2 years.
Deceased's birth name is Emma Jane SIMKIN but at some point over the last 2 years changed it to Emilie Zukiard AFFIN but all her medical records are in her birth name. She lived in a multi occupancy house at the address stated.
Medical background/history: long term mental health issues and was under the Mental Health Team with Paranoia and Bipolar Disorder. Medications: Lithium. Routine bloods taken on 11/12/20. Last contact with GP by telephone 14/12/20. No significant medical issues known.
Working hypothesis at this moment in time is that in the early hours of 20/02/21 deceased had been in the Aldi car park, which is directly above the point of impact, ████████ and was struck by a freight train.
Reported by train driver who contacted his control stating that he had struck something. There is no CCTV at the point of access to the railway lines.
Substantial amount of property recovered from scene including driving licence and notes.
All currently being reviewed. Driving Licence, found on railway tracks and near perceived point of impact, in the name of Emilie Zukiaro AFFIN b. 16/03/1996. Additionally a bag with matching identification located in nearby Aldi car park.
Some notes relate to intimating suicide and mental health issues have been recovered and which are thought to relate to the deceased.
Death confirmed at scene by paramedics at 0342 hrs. BTP officers attended scene. Body badly disrupted. ID confirmed by photo ID found at scene and by fingerprints.
NOK (parents) ████████, have been traced and informed. ████████ has also spoken to them at length.
BTP continuing investigation.
Standard PM required to establish and confirm cause of death. Samples to be taken for toxicology to check for alcohol and drugs/medications. DS
01/03/21 - PM carried out at QMC on 26/02/21 by ████████. Cause of death; 1a Multiple Traumatic Injuries suicide to toxicology. NOK - father BTP updated. Body released.
Please can an Inquest be opened and adjourned in relation to this matter.
Interims to be sent to the deceased's father; ████████ - address on wpc contact tab
Burial Order to be sent to Sun Rising Funerals Warwickshire.
Please write to the following to request reports and statements:
GP re deceased's medical background and history,
LPFT Mental Health Services re engagement with their services
Addaction - We Area With You to establish if deceased had any dealings with them.
All other reports and statements are in hand. DS
06/04/21 - Toxicology and PM reports received. NOK updated. Copies of reports sent to BTP ████████
Toxicology - A low level of ethanol was detected which may have resulted from post mortem changes.
No other significant toxicological findings. The liver tissue sample was unsuitable for lithium analysis.
PM result: 1a - Multiple Traumatic Injuries 1b - Collision with train. DS

Families are repeatedly advising their perception is that loved ones are successfully "masking" their mental illnesses in front of professionals who are perceived to accept at face value what they are told rather than looking at other primary evidence more often than not from the families themselves. which in turn leads the families to believe they are being ignored and lives lost.
Can you reassure me that policies are in place that focus upon how to identify "masking" and adequate training to the appropriate professionals is up to date and consider if policies are in need of review.