“Abbi spent most of her adult life in detention and was Abbi was transferred to a…”

The coroner’s concerns

1. Abbi spent most of her adult life in detention and was Abbi was transferred to a specialist Tier 4 mental health hospital by EPUT for investigation and assessment of her diagnosis who confirmed she did not have personality disorder. Abbi was seen by very junior clinicians even though she was an extremely complex patient. 2. The diagnosis of personality disorder was later reapplied to Abbi by a junior in the community with no rationale recorded and this was not noted or queried by the local community team or Consultant Psychiatrist. 3. In October 2021 Abbi suffered a deterioration in her mental health with reported noncompliance of Clozapine medication. The Consultant Psychiatrist emergency plan was not followed: a. Short-term prescription of Diazepam to assist with an exacerbation of distressing symptoms to permit Abbi’s Clozapine to be re-titrated was incorrectly continued as a permanent prescription in the absence of a medical review and this was not compliant with the NICE Guidelines. b. urgent follow-up required for a predicted and inevitable deterioration in the event of continued non-compliance did not take place. c. Abbi’s medical records were not updated as required; there were omissions in the significant information about Abbi’s clinical condition and Abbi was not escalated back to the Consultant Psychiatrist. These matters were then not understood by the mental health professionals as Abbi continued to deteriorate and increase in Abbi Diazepam was prescribed. 4. Abbi remained on a treatment regime during her last admission and discharge at the mental health Trust that was known and recorded as had not been previously successful. Abbi had positively responded to Clozapine in the past such that Abbi was discharged to supported living from the Tier 4 specialist unit. Abbi’s deterioration with continued non-compliance with Clozapine was recorded by the local community Consultant Psychiatrist as predicted and inevitable. No plans were put in place to mitigate this. 4 5. Abbi deteriorated significantly at the end of January 2022 and February 2022 requiring police to take Abbi to a place of safety due to her presentation and level of self-harm and suicidality that required a Mental Health Act assessment. Professional concerns were raised about inaccurate clinical information contained in the documentation from the Approved Mental Health Act Professional (AMHP) that were about another patient. Abbi made a video about the contents of this letter that reinforced her view that professionals did not care about her. Abbi received an apology about the inaccuracies in this AMHP assessment shortly before her death. 6. There were issues in communication and sharing of information. Evidence was that some EPUT staff did not appreciate Abbi’s history and did not read the medical records or query inconsistencies. Not all clinical contacts were appropriately recorded. 7. Staff at were not trained in Autism or how to communicate with Abbi as a neurodivergent person with a learning disability. Expert evidence was that there was insufficient exploration of how this impacted specifically on Abbi and how best to communicate with her and how information should have been presented to her about her diagnosis, care and treatment. The evidence of some later training was not considered sufficient. 8. There were no professionals’ meetings to consider how best to respond to Abbi when in crisis and how crisis could be mitigated to avoid hospital admission. Abbi was a complex young woman who suffered an obvious and predicted deterioration. 9. Abbi's diazepam was continued and increased during her crisis and deterioration. Abbi was prescribed a treatment medication regime that had been unsuccessful in the past and had not mitigated attempts to end her life by ligature whilst she was detained in her last admission under the Mental Health Act. 10. There were no up-to-date care plans and risk assessments in place for Abbi during her detention and when she was discharged to the community on 14 February 2022 to mitigate a known significant risk. Abbi had tied multiple tight ligatures during her 11day admission under detention of the Mental Health Act and had her usual clothing removed on 4 February due to her risks, the precise date her clothing was returned, and the rationale was not recorded. 11. On 9 February 2022 community mental health staff required 3 conditions to be met before they would support Abbi’s discharge, none of which were met on 14 February 2022. Abbi’s was a very complex patient and her care co-ordinator wanted to attend Abbi’s ward review on 14 February and emailed the consultant psychiatrist that she had not received a link. The ward review went ahead in absence of the care coordinator and concerns that the care co-ordinator had about Abbi’s risks of her harming herself and ending her life on the discharge were escalated. The plan did not change. 12. Abbi had anti-ligature bedding, and her room stripped of her possessions, and this remained in place at the time of her discharge. The responsible clinician was informed by a preceptorship nurse that the Home Treatment Team had refused to accept Abbi as she had a care co-ordinator. This information was known by the treating team to be incorrect, the Home Treatment team had agreed to see Abbi on 25 January 2022, and other patients had been assessed and discharged from the Ward with these arrangements previously. This was not checked or challenged, and Abbi was discharged without further discussion with professionals about an appropriate care plan. 13. Although Abbi had some dialogue about the future on 15 February, she informed the community mental health team that she did not want to go on anymore, had lived her life, could not give any assurances for her safety and was declining help. Advice from the Home Treatment Team was not sought and the community team wanted to step 5 up care, but this had not been put in place and was

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2026-0286

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0