Sarah Sutherland

I make this report under paragraph 7(1) of Schedule 5 to The Coroners and Justice Act 2009.

On 17th December 2023 I resumed an investigation into the death of Sarah Louise Sutherland. On 17th January 2024, the investigation was concluded: The medical cause of death given was: 1a. Suspension I recorded the following in Box 3 of the Record of Inquest: Sarah Louise Sutherland had significant mental health challenges with an ongoing history of suicidal ideation and self-harm. On the 17th December 2022, Ms Sutherland was found to have died by intention through self-suspension at her home address in Redhill having last been known to be alive on the 15th December 2022. I concluded Ms Sutherland died by way of Suicide

Guidelines for regulation and management of private psychotherapists The psychotherapist did not fulfil the UKCP (of which she is a member) Code of Ethics and Professional Practice by failing to keep any clinical records in the care she provided to Ms Sutherland, nor has her practiced changed since Ms Sutherland’s death. The psychotherapist did not at any time undertake risk assessments and blurred if not crossed the boundary of a therapeutic relationship between a therapist and a client. Proactive need for co-ordination of NHS mental Health services and Private Psychotherapy Following Ms Sutherland’s death, Surrey and Borders NHS Foundation Trust have, as long as client consent is obtained, introduced a ‘standard process for communication with private providers of psychological therapies’. However, there is a national lack of co-ordination of treatment and communication between NHS and private providers of mental health care with no formal or informal mechanism or processes in place to liaise with each other to ensure the best mental health care and safety of their clients.

In my opinion action should be taken to prevent future deaths and I believe that the people listed in paragraph 1 have the power to take such action.