Nikolas Clarke represented the local authority: its AMHP and Social Services department in an Article 2 jury inquest concerning SMV who died in April 2019.
An Article 2 inquest is an enhanced inquest in cases where the state or its agents have arguably failed to protect the deceased against a human threat or other risk such that an investigation that complies with the ECHR is required.
Background to the inquest
SMV had psychiatric problems for many years. She had been diagnosed with a personality disorder and had attempted suicide in the past.
From October 2017 she had the benefit of a home treatment team. Then from December 2017 she had treatment at a psychotherapy unit for people that suffer trauma.
In May 2018, the management at the unit asked SMV to leave because she had been misusing codeine.
Subsequently she came into the care of a community mental health team operated by the NHS Trust and with a care coordinator from Social Services.
Although SMV said she was clean of codeine, the community mental health team wanted her to seek treatment for addiction. In addition to this difficulty, SMV said that she was unable to leave her flat to visit the team. The team concluded that SMV was failing to engage with them and discharged her from the service. SMV disagreed with this decision and the evidence was that she had “demonised” the care co-ordinator.
Following a few months of relative stability, matters deteriorated to a point in January 2019 when SMV told professionals she was “sorting out her affairs” so that her death would have less impact on her partner. The implication was that she intended to take her own life.
On Friday 5 April 2019 her private psychiatrist made a referral to the Approved Mental Health Professional (AMHP) for a Mental Health Act assessment. The AMHP proposed an assessment on the following Tuesday, 9 April.
On Sunday 7 April 2019 SMV left her flat and did not return. She was found in her car on Monday 8 April 2019 having taken an overdose.
Her family were critical of:
- the care provided by the community mental health team, particularly the decision to discharge SMV in the summer of 2018
- the failure to undertake a Mental Health Act assessment before SMV’s death.
The coroner's finding and jury's conclusion
In the event, the coroner did not leave either matter to the jury as causing/contributing to the death and the jury gave a short narrative conclusion that did not find any causative factors.