Georgina Fletcher was a 50 year old woman who sadly had a long history of severe mental illness and was under the care of various mental health services. In August 2019, Georgina’s mental health deteriorated. Following two suicide attempts, on 30 September 2019 she was admitted to Finch Ward, Lakeside Mental Health Unit under a section. Her family were of the view that she was extremely unwell and should not leave the ward for ‘unescorted’ leave. Despite having raised these concerns, Georgina was able to leave the ward on 14 October 2019 with a rucksack full of her belongings and a pillow. Georgina did not return to the ward and was returned the next day following the family alerting police.

Two days later on 16 October Georgina was once again allowed to leave the ward unescorted. She went to a local bank with a knife and asked for money and waited for police to arrive. When they arrived, she asked police to shoot her. This was not a planned armed robbery but in fact Georgina was trying to commit suicide by having the police shoot her dead. She was subsequently returned to the ward by police, as she was still under section.

On 17 October 2019, following the bank incident, the Police sent a letter to the ward stating that Georgina wanted to be shot by the police and that in their view she must be kept in a secure unit with no opportunity to leave the ward, whilst they carried out an assessment as to her medical diagnosis and communicated with doctors. They also stated in the letter that there was a very serious risk that Georgina and members of the public would be put at substantial harm if she was released from their care. At the final inquest hearing, all witnesses stated that they never saw a copy of this letter, despite it being in Georgina’s medical records.

The family met with the consultant psychiatrist in charge of the ward on 29 October 2019 and informed all those present at the meeting that Georgina wasn’t well and needed to remain in hospital, as they feared if she left she would take her own life, on the basis of the three suicide attempts prior to this point. The consultant psychiatrist left the meeting before a resolution could be reached and stated he had other patients to deal with. The plan was to rescind the section in 2 days’ time and have Georgina remain on the ward as an informal patient. Georgina had consistently expressed thoughts of self-harm and suicide to her family and to her Care Co-ordinator, which were relayed to staff at Lakeside, but seemingly disregarded.

On 31 October 2019 the family were informed that Georgina would not be let out/have her section rescinded until 3.30pm. In fact, she was allowed to leave the ward at midday and the family nor anyone else was not made aware of this decision. She did not return to the ward. Despite the police undertaking an extensive missing person investigation, Georgina was tragically found hanging from a tree in Hounslow Heath woods on 17 November 2019.

Following an inquest hearing lasting five days the jury found the following:

1) There was a failure of communication between the Hospital and the Deceased’s family which possibly (but not probably) contributed in a more than minimal way to her death; 2) There was a failure of communication between ward staff at the hospital which possibly (but not probably) contributed in a more than minimal way to her death; 3) There was a failure by the Hospital staff to communicate with the community care co-ordinator and this failure possibly contributed in a more than minimal way to the deceased’s death; 4) There was a failure by the Hospital staff to communicate appropriately with the Police and this failure possibly contributed in a more than minimal way to the deceased’s death; and 5) There was a failure to circulate the deceased as a missing person on 31 October 2019 which possibly (but not probably) contributed in a more than minimal way to her death.

Siobhan Fletcher, Georgina’s daughter, who was in regular contact with the hospital and repeatedly reported her concerns to staff said that: “It was clear from the beginning that the consultant psychiatrist in charge of my mother’s care did not take her seriously, nor did he take any of my concerns seriously. Had he done so, and had the hospital properly communicated with us, with each other and with the police regarding my mum’s release, she would still be here today”. Georgina Fletcher’s family was represented by Tessa Hutchinson of GT Stewart and Laura Profumo of Doughty Street Chambers.