Charne Nikita Petit · Prevention of Future Deaths report

On 30th May 2023 an inquest was opened into the death of Charne Nikita Petit. The inquest was concluded on 30th July 2024.

The medical cause of death was: 1a. Suspension.

The narrative conclusion was that:

Charne Petit suffered from psychotic delusions which she found extremely distressing. From 2019 to 2022 she was treated by the early intervention in psychosis team. Thereafter her care was transferred to the community mental health team. Her symptoms and mood fluctuated, in addition, on occasions, non-compliance with anti-psychotic medication and use of illicit drugs triggered relapses in her mental health.
On the 26th March 2023 she suffered a psychotic breakdown and was assessed under the Mental Health Act and found to meet the requirements for detention under s2. No mental health bed was available. She was nursed one to one in the Royal Surrey County Hospital by nurses from the psychiatric liaison team. She was re-started on aripiprazole and her mood stabilized. She was discharged to the home treatment team on the 31st March 2023 without an assessment followed by medical treatment in a mental health hospital.
On the 24th April she was seen by her care coordinator and reported intrusive psychotic delusions and struggling to manage her emotions. On the 25th April 2023 she represented to Royal Surrey County Hospital having abused drugs. She was assessed not to require a mental health assessment and discharged. On the 12th May 2023 she killed herself by suspending herself ████████ ████████ effective treatment of her psychosis. The lack of a mental health hospital bed after she was assessed as detainable under s2 more than minimally contributed to the death.

She died by Suicide

See the details set out in the narrative conclusion.

In addition:

Ms Petit was reviewed in hospital on the 29th March 2023 by a consultant from the liaison psychiatry team. Her presentation had improved since admission and in his opinion, so long as she continued to improve, she could be discharged to the home treatment team and that this was the least restrictive option.

The effect of the discharge on the 31st March 2023 was that Ms Petit was not admitted to a mental health hospital under section 2 of the Mental Health Act 1983 and was therefore discharged without having been assessed comprehensively in a mental health hospital.

(1) Evidence given by the court appointed expert consultant psychiatrist was that Ms Petit was not adequately medicalised and that she needed assessment and medical review with optimisation of treatment in a mental health hospital. Her response to treatment needed to be observed. This is what a s2 admission is designed to effect. The lack of a bed in a mental health hospital denied Ms Petit this opportunity for optimal treatment.

(2) The Court heard that owing to a shortage of mental health beds patients who have been assessed by 2 s12 consultant psychiatrists to require detention after a mental health act assessment are being effectively detained in general hospitals without a section, awaiting a bed, because they cannot be placed under section unless a mental health bed is available.