“Abbi had admissions to the acute Trust in January and February 2022”

The coroner’s concerns

Abbi had admissions to the acute Trust in January and February 2022. 1. There were not sufficient trained staff to conduct the enhanced observations required to monitor Abbi with her known risk of severe self-harm whilst she was awaiting assessment under the Mental Health Act and actively attempting to take her own life. 2. For a period of time Abbi was left under the observation of staff that were security personnel and were not appropriate or trained to undertake this work. Male security staff were informed that Abbi should use a commode due to her presenting risks and there were not sufficient trained female staff available. There had been a previous incident where actions taken to restrain Abbi by security personnel caused her trauma and there had been an allegation of assault, this was not considered in this admission. 3. Abbi at times had to be physically and chemically restrained due to the level of distress and harm to herself. During her admissions Abbi was able to access ligature material that she tied around her neck on multiple occasions over multiple days including her socks, cords from her clothing and pull cords in the bathroom. There were no appropriate care plan and risk assessments to mitigate a significant known risk. 4. Abbi was a complex mental health patient awaiting assessment under the Mental Health Act and was being cared for in a part of the hospital that was not suitable for a patient who was actively attempting to take her life. 5. Staff left Abbi unsupervised during the admission to attend to other patients that permitted her to tie ligatures. 6. No adjustments or plans were made for communication for Abbi as a patient with Autism and learning difficulty 4 10. COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every Interested Person who in my opinion should receive it. I also may send a copy of the report to any other person who I believe may find it useful or of interest. I can confirm I have sent the report to: [please do not use individual’s names, but instead roles/titles] 1. Care Quality Commission I also have a duty to send a copy of the report to the Chief Coroner. You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026). Any representations will be sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional information relating to the publication of reports and responses. SIGNATURE 5

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, 2026-0288

Added to Minute Book

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