Francis Hoar acted for a local authority in an Article 2 jury inquest into the death of DG, a 42-year-old woman who died in prison. She had been arrested for trying to kill her mother during a psychotic episode.
DG, who had a diagnosis of schizophrenia, had been under the care of the community mental health team for many years.
In November 2021, her mother became concerned that DG was relapsing. However she was unable to get an urgent full assessment of her daughter by the community mental health team.
Five days later, she took DG to the Community Mental Health Centre, but they were not seen by a specialist nor was a new mental health assessment carried out.
A few hours later DG stabbed her mother and was arrested. The police officers thought she needed an urgent mental health assessment.
But the consultant at the hospital where she was taken did not carry out an assessment under the Mental Health Act 1983 (the MHA). Francis’s client was responsible for the Approved Mental Health Professional (AMHP) who was called for advice while DG was in hospital. His cross-examination confirmed that the AMHP was not told about DG’s diagnosis or any of her previous detentions in hospital under the MHA. DG was discharged and transferred to the police station.
She was formally charged with attempted murder and remanded to prison. There, she took her own life and was found dead in her prison cell on 20 November.
Article 2 jury inquest
The Article 2 jury inquest took place over 5 weeks and involved 11 individuals, companies and public bodies as interested persons (2 were represented by KCs).
At the inquest, DG’s cause of death was recorded as cardio-respiratory collapse.
The jury’s conclusion
The jury concluded that:
- ‘numerous opportunities’ for a mental health assessment to be carried out were missed – these would likely have led to DG being held in a mental health unit rather than being remanded in prison
- failings by multiple agencies, including the community mental health team, the hospital, police and prison where DG was remanded ‘“possibly contributed more than minimally to her death” and
- the police should have used their s.136 Mental Health Act powers to divert DG to a hospital for specialist mental health treatment.
However, no findings were made against Francis’s client.
The senior coroner will issue a prevention of future deaths report.