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Death of Sarah Adams was caused by failures in planning her discharge from hospital, concludes Reading coroner

Failures in discharge planning by Cygnet Harrow Hospital and Berkshire Healthcare NHS Foundation Trust (BHFT) probably caused the death of Sarah Adams, a coroner has concluded.

Posted on 18 March 2024

Other failings by BHFT before Sarah’s hospital admission also possibly contributed to her death, said Assistant Coroner Alison McCormick, who will issue a Prevention of Future Deaths report to Cygnet Harrow Hospital, to BHFT and to Reading Borough Council (RBC).

Sarah, aged 64, was found deceased at her home in Reading on 19 May 2022, less than 24 hours after being discharged from Cygnet Harrow Hospital in London, where she had been a psychiatric inpatient.

Sarah Adams
Image of Sarah Adams

Sarah was discharged without a care package in place and with a large amount of medication, despite having attempted to take her own life on 4 April 2022, which led to her admission to hospital. 

Following a four-day inquest at Reading Coroners Court, the coroner gave a narrative conclusion, recognising that issues relating to Sarah’s discharge from hospital and the support provided to her after she returned home contributed to her death. She also ruled that there had been an arguable breach of Sarah’s ‘right to life’ under Article 2 of European Convention on Human Rights, on the basis that Cygnet and BHFT had assumed responsibility for Sarah’s care, that Sarah was particularly vulnerable and that the organisations should have known that there was a real and immediate risk to Sarah’s life.

Sarah’s niece, Izzy Adams, told the court that she felt her aunt had been badly let down by Cygnet Harrow, by mental health services at BHFT, and by RBC social services. 

Izzy told the inquest that she played a big role in caring for Sarah and liaising with professionals about her care and treatment, particularly from September 2021 onwards when Sarah’s mental health declined.

Sarah had a long-standing diagnosis of paranoid schizophrenia but had lived independently in a flat in Tilehurst from 2007, with the support of her family. Izzy told the inquest that the following years were the most stable period she had known in Sarah’s life. Sarah was a loving aunt to Izzy’s children, who she spent a lot of time looking after during this period.

The decline in Sarah’s mental health in the autumn of 2021 began after her mother became unwell and Sarah suffered a relapse in symptoms of her schizophrenia. Sarah’s family became very concerned about her and, as a result, she was referred to the Reading Crisis Team and to Reading Borough Council social services. Izzy gave evidence at the inquest that she did not feel that her concerns about Sarah were fully listened to by the Crisis Team and did not understand what the plan was for her.

In October 2021, Sarah was discharged by the Crisis Team and referred to the Community Mental Health Team. However, the Community Mental Health team had a significant waiting list at the time. As a result, Sarah was not allocated a care co-ordinator and no review of her medication was carried out for several months. At around the same time, social services closed Sarah’s case without carrying out an assessment of her care needs on the basis that Sarah had declined their support during a telephone conversation.

In the following months, Izzy continued to have serious concerns about Sarah’s mental health and regularly contacted mental health services to seek support for Sarah and to explain that she was no longer able to cope with caring for her.

In March 2022, Izzy raised concerns with mental health services about Sarah expressing suicidal thoughts. As a result a review of Sarah’s medication was carried out by the Community Mental Health Team in late March 2022.

On 4 April 2022, the day before Sarah was due to have a follow up appointment with the Community Mental Health team, Izzy found Sarah collapsed after an attempt to take her own life and called an ambulance. Sarah was admitted to Royal Berkshire Hospital before being transferred to Cygnet Harrow Hospital as a voluntary psychiatric inpatient on 6 April.

The court heard that Izzy felt she had reached breaking point after finding Sarah following the suicide attempt, having cared for her aunt for so many months and made countless attempts to obtain the professional care and support which Sarah needed.

While Sarah was at Cygnet Harrow Hospital, the court heard that staff allowed Sarah to call Izzy frequently, often late at night, when she was in a manic state. Eventually, for the sake of her own mental health, Izzy had to block the calls.

On 18 May, Sarah was discharged from Cygnet Harrow despite Sarah’s social worker raising concerns about the discharge on the basis that the package of care which Sarah needed was not yet in place. Sarah was provided with five days’ worth of medication to take home with her. The plan was for Sarah to receive twice daily visits from the Crisis Team following her discharge to assess her mental state and support her with her medication. However, the Crisis Team did not visit Sarah at home on the day of her discharge and the court heard evidence that the professionals involved at Cygnet Harrow, the Crisis Team and social services did not have the same understanding of what the plan was for supporting Sarah on the day of discharge. The court heard evidence that Sarah’s brother was informed of her discharge but none of the family had been involved in discussions about the care and support that would be provided to Sarah once she returned home.

The inquest also heard evidence that, on the evening of 18 May, Sarah told one of her neighbours that she “had been sent home with a load of tablets and didn’t know what she had to take” and that the hospital had told her that a nurse would come to see her at home but this had not happened.

Sarah was found deceased at her home by her brother on the morning of 19 May. Izzy only became aware after Sarah’s death that she had been discharged from hospital.

Giving her conclusion, the coroner said that, on the balance of probabilities, Sarah’s death was contributed to by care and service delivery issues around her discharge from Cygnet. Specifically, the Coroner found that both the misunderstanding about whether the Crisis Team would visit Sarah on the day of her discharge and the decision to provide her with five days’ worth of medication probably contributed to her death. In addition, the Coroner recognised that failings by BHFT in caring for Sarah before she was admitted to hospital may have contributed to her death. These failings related to the delay in actioning the plan for Sarah’s care when she was discharged from CRHTT in October 2021 and to BHFT’s inadequate response to Sarah’s mental health deterioration in February and March 2022.

Sarah’s family was represented by Leigh Day human rights solicitor Dan Webster, paralegal Tasmyn Ong and by Counsel Sophie Walker of One Pump Court Chambers.

Following the conclusion of the inquest, Izzy Adams said:

“My family and I were devastated by Sarah's death and we feel that she was very badly let down by mental health services, social services and Cygnet Hospital in the months leading up to her death. I did all that I could to care for Sarah and to get her the support she needed. I feel strongly that I was not listened to by professionals and that they failed Sarah.

“I still do not understand how Sarah could be discharged from hospital without the support she needed and with a large supply of medication, when she had tried to take her own life just a few weeks earlier. lt was clear that Sarah was not able to understand or manage her medication and I feel strongly that Sarah should never been left in charge of it.

“I am grateful to the coroner for her detailed investigation of what happened to Sarah and for recognising that there were significant failures which led to her death. I hope that this contributes to meaningful changes so that other families do not have to go through what we have been through.

I would also like to thank my legal team, Sophie Walker, Dan Webster and Tasmyn Ong, for their support in helping to achieve this outcome.”

Izzy Adams is represented by Leigh Day human rights team solicitor Dan Webster, who said:

“The Coroner carried out a thorough investigation of the circumstances that led to Sarah's death and found a number of failings by the services involved in caring for Sarah. The conclusion is testament to the huge efforts made by our client to advocate for Sarah both before she died and since her death. It reflects what Sarah's family have always believed: that they did all that they could to seek the professional care and support that Sarah needed and that Sarah was badly let down by the services that were meant to support her throughout the last nine months of her life.

As is evident from the conclusion, the management of Sarah's discharge from Cygnet Harrow and the communication and planning between the professionals involved was entirely inadequate and this led to Sarah’s death. Sadly, this is far from the first time that a coroner has raised concerns about failings by a Cygnet hospital leading to a patient's death. Sarah's family feel strongly that there are significant lessons to be learned and that the Coroner’s powerful conclusion must lead to meaningful change, so that there is no repeat of what happened to Sarah.”

Dan Webster (1)
Human rights Inquests Judicial review Public law

Dan Webster

Dan is an associate solicitor in the human rights department

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