Coroner raises concerns as inquest into woman’s death concludes after almost four years
A coroner is concerned that more people might die unless action is taken after the death of an 18-year-old.
At the end of the inquest into Chloe Louise Barber’s death, Professor Paul Marks, the senior coroner for Kingston Upon Hull and the County of the East Riding of Yorkshire, concluded that “there is a risk that future deaths will occur unless action is taken”.
According to a prevention of future deaths report by Professor Marks, Ms Barber was found dead at her home in November 2021. The death was ruled a suicide.
Professor Marks’ report explained that Ms Barber had a history of self-harm and her last admission to hospital was to the Cygnet facility in Sheffield.
The coroner said she showed improvements there, but was at a point where she was moving from children’s and adolescent mental health services to adult services, and she was not engaging with the new team.
Professor Marks found that there had been valid concern about the lack of documentation and poor communication between services and partner organisations.
The coroner noted that changes to medication may have led to emotional instability and impulsive behaviour, and this was one of a number of issues which may have contributed to her death on November 3, 2021.
While Professor Marks said there was no realistic opportunity to prevent her death, he has given healthcare bosses 56 days to outline the actions they are taking to prevent future deaths.
He highlighted areas of concern in relation to Ms Barber’s death:
Evidence was heard that there is a nationwide concern that there is no clearly defined pathway that assists young persons making the transition between Childhood and Adolescent Mental Health Service (CAMHS) and adult psychiatric services, to ensure a smooth transit and continuity of care.
Concern was raised that there are no clear guidelines about where and by whom depot preparations of antipsychotic may be administered.
There was “considerable uncertainty and ignorance” about the provision of aftercare between some healthcare workers and social workers.
NHS England, the Royal College of Psychiatrists and Minister of State, Department of Health and Social Care must now respond to the coroner to outline their plans.