Louise Crane

I am Ian Potter, assistant coroner, for the coroner area of Inner North London.

On 20 September 2024, an investigation was commenced into the death of  Louise Elizabeth Amy Crane, aged 39 years at the time of her death. The  investigation concluded at the end of an inquest heard by me between 2 June and 10 June 2025. The inquest concluded with a short-form conclusion of suicide. The medical cause of death was: 1a ligature compression to the neck

Louise Crane had an established diagnosis of Emotionally Unstable  Personality Disorder (EUPD). She also had diagnoses of depression and  psychosis (in the context of drug use). Ms Crane first came into contact with mental health services in 2012, since then she had been treated in the community, in voluntary in-patient settings, and while detained under the Mental Health Act. Ms Crane was admitted to hospital for emergency treatment in relation to her  physical health on 2 May 2024, following an attempt to end her life. Once  medically fit for discharge, Ms Crane was admitted to an in-patient psychiatric ward at Highgate Mental Health Centre (North London NHS Foundation  Trust), under section 2 of the Mental Health Act. This detention commenced  on 4 June 2024. Following Ms Crane’s initial admission to Highgate Mental Health Centre, she was transferred to a psychiatric intensive care unit (Ruby Ward) on 5 July  2024. Ms Crane remained on Ruby Ward until she was stepped down to an  acute mental health ward (Topaz Ward) on 5 September 2024. On 19 September 2024, when Ms Crane remained detained under section 3 of the Mental Health Act, she was found in her room suspended by a  dressing gown cord used as a ligature. The jury’s findings as to how, when, where and in what circumstances Ms Crane came by her death were, as follows: “Louise Crane died in Highgate Mental Health Centre on 19 September 2024 from a ligature compression to the neck. Factors contributing to Louise’s  death were a chronic high risk of suicide linked to Emotionally Unstable  Personality Disorder, in combination with unsatisfactory information sharing  and recording, and inadequate risk management, staffing and levels of care  and treatment during Louise’s time on Topaz Ward.”

During the course of the inquest the evidence 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 MATTER OF CONCERN is as follows: 1) Evidence from a senior member of North London NHS Trust’s clinical leadership team revealed that there is a lack of a nationwide policy /  approach to anti-ligature measures in mental health settings.

In my opinion, action should be taken to prevent future deaths and I believe that you have the power to take such action.