Warnings missed before woman’s death in Harlow says coroner

Crime / Wed 10th Jan 2024 at 08:46am

LESSONS need to be learnt after warnings a 59-year-old was intending to end their life were missed, the coroner for Essex has said reports the Local Democracy Reporter.

Amanda Hitch died near railway tracks at Harlow Mill on February 12, 2022, in Harlow while in the care of a community mental health team under the Essex Partnership University Trust. 

However, during the inquest in December 2023, it became clear that one significant entry in the clinical notes made by someone in a separate service commissioned by the Essex Partnership University Trust, which expressed a very specific and imminent intention from the deceased to end her life, was not seen by others in the clinical team.

The assistant coroner for Essex Stephen Simblet KC has said was almost certainly because the clinical record does not present on computer screens as a continuous chronological running record, but is instead viewed thematically.

That means that readers are likely to look at entries made within their particular clinical team, rather than see what others have recorded more recently.

He said in his Prevention of Future Deaths report: “There is an obvious risk that critical and important information garnered by others and put into the medical records will not be seen, and that those making clinical decisions on risk management will thus be unaware of potentially very significant information.”

The inquest also heard evidence about the measures that the British Transport Police had taken, seeking to provide additional support by setting up a multi-agency support plan, which provided a system for alerting several people including Ms Hitch’s care coordinator, when she visited railway stations.

For various reasons, although there are several known attendances at railway stations, none were passed on to the care co-ordinator.

The evidence at the inquest was that British Transport Police does not have the resources always to provide information about attendances at unstaffed stations – although one such attendance had been known about but was not passed on.

Mr Simblet  said: “Should it remain the position that BTP lacks the resources to identify all such attendances at railway stations by persons at specific risk of suicide on the railway, there is a risk that those expecting to receive information under such a plan may not realise that the plan will often not assist where its subject is attending unmanned stations.”

A spokesperson for Essex Partnership University NHS Foundation Trust (EPUT) said: “The death of anyone in our care is devastating and our sympathies remain with Amanda’s family and friends.

“Our community mental health teams are continuously focussed on providing person-centred and compassionate care, working with health and care partners to support patients to lead full and independent lives.

“We are reviewing the Corner’s findings to ensure learning is shared across the organisation to continually improve the services we provide and will respond to the report in due course.”

Inspector Philippa Smith from BTP Public Protection and Vulnerability Team, said: “Our sincerest condolences remain with Amanda’s family. The Inquest into Amanda’s death underlined the important work carried out by our Vulnerability Unit.

“In light of this report, we are reviewing our training and processes to ascertain if there is anything additional we can implement to improve external organisations understanding of risk of harm on the rail network.”

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2 Comments for Warnings missed before woman’s death in Harlow says coroner:

Matthew Durham
2024-01-10 12:58:11

Firstly my prayers are with the family. Frankly I am not surprised. I have attended the community mental health team at latton bush in distress ( I have mental health issues) with my mother and was turned away!I know a few people under them and I am yet to find anyone who rates the service well.

David morton
2024-01-14 22:55:02

Such a shame, no age either, thoughts with this poor woman and her family.

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