Coroner to issue Prevention of Future Deaths report to NHS trust over domestic abuse and suicide risk following death of 36-year-old

A week-long inquest into Erika's death was held at Devon Coroner's Court in Exeter in July 2026. Erika had a history of mental health difficulties and had shown a decline in health in the months before her death in March 2021.

Recording a narrative conclusion, the coroner concluded that Erika died from an overdose and that it was not possible to determine her intention or state of mind at the time the tablets were taken. She found that the evidence did not support a conclusion of suicide on the balance of probabilities.

The inquest examined the response to Erika by Devon & Cornwall Police, her GP practice and Devon Partnership Trust’s First Response Service from December 2020 – March 2021 in the period before her death. The coroner identified shortcomings in the response of all three agencies, including deficiencies in the way domestic abuse and suicide risk were explored and recorded.

In relation to Devon Partnership Trust, the coroner found that the staff working with Erika failed to sufficiently explore the domestic abuse she faced. For example, risk assessments were inadequately recorded and there was no clearly documented safety or care plan in December 2020 or anytime thereafter. Erika’s relationship with her partner was also not properly examined, despite evidence heard at the inquest that the Trust was aware that Erika faced domestic abuse during the time she was under their care.  

Submissions made by Erika's family had argued that her death raised important issues about the relationship between domestic abuse, deteriorating mental health and suicide risk, and the need for frontline services to better understand and respond to those risks. They submitted that agencies repeatedly failed to identify Erika as a victim of domestic abuse, discuss her experiences with her and involve her in a plan to keep her safe.

Despite officers from Devon and Cornwall Police twice attending Erika’s home in the days before her death, there was a failure to recognise that the ex-partner present at home was a domestic violence perpetrator who had previously been subject to a Domestic Violence Prevention Order. 

The coroner heard expert evidence about the general relationship between domestic abuse, mental ill-health and suicide risk, including that the link between domestic abuse and suicide is increasingly recognised and that women with pre-existing mental health difficulties can be particularly vulnerable.

However, while identifying shortcomings by the police, GP practice and mental health services, the coroner concluded that it could not be established that those failings had made an actual and material contribution to Erika’s death.

The coroner also decided that Article 2 of the European Convention on Human Rights was not engaged and found that, although Erika was vulnerable and there were signs of deteriorating mental health and suicidal ideation, the circumstances did not give rise to an operational duty to protect her life.

She declined to issue Prevention of Future Deaths reports to Devon & Cornwall Police and Pembroke Road Surgery, noting changes and improvements that had been made since Erika’s death. However, the coroner concluded that a formal report to Devon Partnership Trust was necessary because concerns remained about the need for training on the relationship between domestic abuse, mental health deterioration and suicide risk.

The family’s submissions had highlighted evidence that Erika disclosed domestic abuse and suicidal thoughts to services in the period before her death, and argued that mental health professionals should have taken a more proactive approach to understanding her circumstances and safety. They argued that greater professional curiosity, coordinated safeguarding and specialist domestic abuse support could have reduced missed opportunities to intervene.

Erika's mother Elizabeth Turner is represented by Leanne Devine and Emily Driver, human rights solicitors at law firm Leigh Day. The family are being supported by Advocacy After Fatal Domestic Abuse (AAFDA). They have also received assistance from the Centre for Women’s Justice (CWJ) and INQUEST.

Elizabeth said:

"Erika was my much-loved daughter, and she was so much more than the circumstances of her death. She was kind, generous and loving, and we miss her every day. It has been incredibly difficult to hear about the shortcomings and missed opportunities in the way different agencies responded when Erika was struggling. 

"It has been more than five years since Erika died, and it is deeply difficult to know that concerns about training which the trust acknowledged was needed have still not been formally timetabled or implemented. We have been through a lengthy and very difficult process to reach this conclusion stage, including a difficult inquest, and I hope that the concerns now formally raised will finally lead to action.

"Although the coroner could not find that those failings caused her death, I hope that the Prevention of Future Deaths report means that lessons will now be learned.

"If better understanding of the link between domestic abuse, mental health and suicide risk can help another woman get the support and protection she needs, then I hope something positive can come from losing Erika."

Emily Driver, human rights solicitor at Leigh Day, said:

"The coroner has identified important shortcomings in the way Erika’s circumstances were understood and responded to by the agencies involved in her care and support.

"Most significantly, the coroner has decided that a Prevention of Future Deaths report is necessary in relation to Devon Partnership Trust because concerns remain about training on the relationship between domestic abuse, deteriorating mental health and suicide risk. That is an important outcome from this inquest.

"Erika’s family hope that the action now required of the trust will lead to meaningful change and that professionals working with people experiencing domestic abuse will be better equipped to recognise the risks they face and provide appropriate support."