Rachael Gourley represents family of Amanda Hitch who died after failures in mental health care and treatment
1st February 2024
The inquest into the death of Amanda Hitch found that inadequate mental health care contributed to her death. A preventing future deaths report was issued.
The Article 2 inquest considered the mental health care and treatment provided to Mandy and the role of British Transport Police. Mandy was a known frequent attender at railway stations at times of distress.
Mandy’s escalation in risk and clear suicidal intent was missed by clinicians despite her repeated engagement with services in late January and early February 2022.
The Coroner returned a narrative conclusion which found that the level of risk that Mandy presented “was not sufficiently appreciated and not sufficiently addressed.” The Coroner found that “no formal risk assessment tools were used.”
The Coroner found that the plan made with British Transport Police “may have created a false sense of security” as between BTP and the Mental Health Trust, arising from a lack multi-agency working. Mandy was attending unstaffed railway stations and BTP does not have the resources to identify or report such attendances.
Overall, the Coroner concluded that omissions by the Mental Health Trust contributed to Mandy’s death in that there were “plainly interventions that could have been taken and would have served to protect Mandy from the known risk, and not considering those contributed to her death.”
The Coroner identified a risk of future deaths and issued a Preventing Future Deaths report under Regulation 28 to:
- NHS England;
- British Transport Police; and
- Essex Partnership University Trust.
The inquest was covered in the BBC here.
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