
Inquest finds mother of two suffering from psychotic depression took her own life whilst on unescorted leave from mental health hospital
An inquest into the death of 34-year-old Abigail Menoret has concluded that she died by suicide whilst on unescorted leave under the care of Berkshire Healthcare NHS Foundation Trust.
Posted on 16 October 2024
Recording a verdict of suicide, the jury added a narrative detailing the events that led up to Abi’s death.
The inquest at Reading Coroner’s Court investigated the circumstances surrounding Abi’s suicide on 10 September 2023.
Image of Abigail Menoret
Area Coroner for Berkshire, Hannah Godfrey, confirmed that she will consider whether to release a Prevention of Future Deaths report regarding the failings in care of the trust. This decision will be taken within ten days.
Abi, from Maidenhead, had been suffering from postpartum psychosis following the birth of her second son in January 2022. She was a patient at Prospect Park Hospital in Reading under Section 3 of the Mental Health Act, having previously struggled with postnatal depression after both of her pregnancies.
On 10 September 2023, during a period of unescorted leave granted by the hospital, Abi took her own life at home. She had made plans to do so on 7 September, when she pre-booked a taxi to take her there, as she knew that her husband and children would be away in France.
The inquest explored the circumstances leading up to Abi’s death, including multiple suicide attempts during her treatment at various hospitals, frequent changes in both her medication and her responsible clinicians, and concerns raised by her husband, François-Marie Menoret, about the management of her care and her leave arrangements.
The inquest heard evidence from the clinicians involved in Abi’s care, as well as the trust’s Lead for Suicide Prevention, who discussed the steps the trust has taken to increase training for staff, ensure a collaborative approach with families involved in patients care and to reiterate the importance to staff of both completing leave documentation accurately and contacting next of kin once a patient has not returned.
François-Marie, who is represented by solicitor Frankie Rhodes of Leigh Day, expressed his concerns regarding the care provided at Prospect Park Hospital. He outlined that his wife was allowed increasing periods of unescorted leave despite her persistent delusions and the recognised ongoing risk of suicide.
On the day of her death, she had been permitted a one-hour period of unsupervised leave, which was an increase on the time she had previously been authorised, despite warnings about her increased risk of self-harm around the anniversary of her admission and particularly whilst her husband and children were away visiting family in France. These concerns about going away should have been documented as red flags.
The inquest heard about the lack of continuity in Abigail’s care, with frequent changes in consultants, regular alterations to her medication and inconsistent involvement of the family in key decisions. The family also raised concerns about the risk assessments that were carried out and the decision-making process surrounding Abi’s leave.
Abi’s husband and the police were also not contacted soon enough after she went AWOL, in breach of trust policy, which states that the timeframe should be thirty minutes after the patient is identified as having not returned on time.
The jury heard evidence regarding the failings in communication and the difficulties posed by Abigail’s condition, which often made her appear outwardly well, even when she was not.
Abigail’s family describe her as a “remarkable woman, mother, wife, daughter and friend.”
Abigail’s husband, François-Marie Menoret, said:
“I feel let down by the clinicians who were responsible for Abi’s care. The lack of consistency meant that it was difficult to form relationships with staff and every time there was a change, it felt like we were starting all over again. Each consultant had different views about what was best for Abi and what type and dose of medication she should be on.
“Ultimately, the major issue was the failure to consider my very real concern that Abi would try and take her own life while I was away in France with our sons. I trusted those looking after her to monitor her closely, and to find out that her leave allowance and therefore her freedom to go outside the hospital on her own had in fact increased during this time was a huge shock to me. I am devastated by the loss of my beautiful wife, who was a loving and devoted mother to our two sons.”
Clinical negligence solicitor Frankie Rhodes said:
“I am glad to have been able to offer support to Francois-Marie at such a harrowing time for his family. It is tragic that Abi died so prematurely, leaving behind her much-treasured young sons.
“The trust’s own Serious Incident report which was carried out as part of the investigation highlighted that there is a lack of documented evidence to show that changes in leave arrangements were discussed and considered more widely during multi-disciplinary team meetings and with Abi's husband. There were failures in filling out leave forms and there were gaps in the sign in/out record when leave took place. Risks regarding holiday were also not clearly documented as part of risk assessment for patients.
“In light of these failings, I am disappointed by the coroner’s decision not to allow the family’s representative to raise questions with the trust on the central issue of what has been implemented already and what is going to be changed to ensure something like this does not happen again.
“As a result, I am concerned about the absence of a clear record of what the trust is going to do in future to minimise human error in the management of its processes to avoid tragic outcomes like the one suffered by our client.”