Sarah Adams

I am Alison MCCORMICK, Assistant Coroner for the coroner area of Berkshire

On 27 May 2022 I commenced an investigation into the death of Sarah Elizabeth ADAMS aged 64. The investigation concluded at the end of the inquest on 18 March 2024. The conclusion of the inquest was that: Ms Adams died by suicide; however, her death was more than minimally contributed to by care and service delivery issues around her discharge from a voluntary in-patient hospital admission for a relapse of her longstanding paranoid schizophrenia and an intentional medication overdose.

Sarah Adams was found deceased at her home address on 19th May 2022. She died from a self administered overdose of prescribed medication taken with the intention of ending her life. On the balance of probability Ms Adams’ death was more than minimally contributed to by care and service delivery issues around her discharge on 18th May 2022 from a voluntary in-patient hospital admission for a relapse of her longstanding paranoid schizophrenia and an intentional medication overdose taken on 4th April 2022. Specifically, a misunderstanding about the Crisis Team visiting Ms Adams on the day of her discharge together with the provision of 5 days of prescribed medication to her likely made a more than minimal contribution to her death. The following care and service delivery issues possibly made a more than minimal contribution to Ms Adams’ death: Delay by the mental health Trust in actioning the care plan on Ms Adams’ discharge from the Crisis Team in October 2021, both in respect of allocating a Care Co-ordinator to her and in arranging an Out Patient Appointment and medication review;The mental health Trust’s response to Ms Adams’ deterioration in February and March 2022.

During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) That clinicians and other hospital, mental health Trust and Social Care practitioners involved in the discharge of patients from in-patient mental health admissions are not trained in the discharge process generally and specifically the issues which may arise in respect of out of area admissions

In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action.