Patient took own life day after discharge - inquest

Sarah Adams was found in her Reading flat the day after being discharged from a psychiatric hospital

A psychiatric patient took her own life less than 24 hours after being discharged from hospital without a care plan in place, an inquest has heard.

Sarah Adams, who had schizophrenia, was found dead at her home in Reading on 19 May 2022.

Berkshire Coroner's Court heard the 64 year old had been expecting a visit from an NHS crisis team on the day she died - something she believed had been arranged by Cygnet Hospital Harrow in London.

Coroner Alison McCormick recorded a narrative conclusion.

Ms McCormick said Ms Adams was admitted as an inpatient after she attempted to take her own life on 4 April.

This was due to her feeling "overwhelmed" and "not knowing what was happening with her health", the court at Reading Town Hall heard.

Her condition was reported to have improved during her stay, but she was discharged on 18 May without a care plan in place, Ms McCormick said.

Ms Adams had been an inpatient at Cygnet Hospital Harrow

The coroner said a misunderstanding led to Ms Adams being told that twice daily visits from a crisis team - an interim measure until her care package was in place - would begin the day she was discharged.

But the court heard they were actually not supposed to begin until the day after.

Ms McCormick said the crisis team not turning up would have caused Ms Adams to feel her care plan had "failed on day one", highlighting to the court that her previous suicide attempt had been due to her feeling out of control and not knowing what was going on.

She said this idea was supported by evidence from Ms Adams' neighbours, who reported she had told them she did not understand what medication she was supposed to take and when.

They said she "was not her usual bubbly, happy self" and that she said she "did not know how to laugh anymore".

Ms Adams was found dead in her flat the following morning.

'Lessons learned'

Ms McCormick concluded that the misunderstanding about the crisis care team, the fact Ms Adams was discharged with five days' worth of prescription medication, and and lack of an established and consistent care team - among other factors - likely contributed to her death.

She said she would issue a Report to Prevent Future Deaths to the hospital, Berkshire Healthcare NHS Foundation Trust and Reading Borough Council's adult social care services, to ensure adequate training is given to anyone involved in patient discharges.

A spokesperson for Cygnet said it would "always seek to ensure lessons learned are identified and shared".

They added they "have been working hard" to address the issues raised, including by appointing a new hospital manager and reviewing elements of their discharge policy.

Berkshire NHS Trust said it recognised it "could have done things better" and had since put "improved processes" for patient discharge in place.

A spokesperson for Reading Borough Council said the authority would continue to work with the NHS trust to ensure patients were discharged safely.

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