“Evidence was given during the inquest by SBP staff on the ward concerned, that the reason…”

The coroner’s concerns

– (1) Evidence was given during the inquest by SBP staff on the ward concerned, that the reason SBP staff did not arrange to collect Sasha and return her to the ward when her s.17 leave had been revoked, was that they did not have the resources to allow them to do this, despite it being their legal responsibility so to do. (2) Sasha’s mother gave evidence that SBP’s reliance on her bringing Sasha back to the ward when s.17 leave had been revoked, placed an unfair and intolerable burden on her, in circumstances when she and the rest of the family were struggling to keep Sasha safe. Knowing that SBP would not send someone out to collect Sasha made her feel that she had no choice but to agree to their request. (3) The last such occasion when SBP staff on the ward decided that Sasha’s s.17 leave should be revoked was on the afternoon of her death on 31.3.17. Although formal revocation of leave was never finalised, Sasha’s mother was given to believe that it would be, and again reluctantly agreed to bring Sasha back to the ward. Whilst with her mother, Sasha was able to run off and take the substantial Propranolol overdose which proved to be fatal. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you ( and/or your organisations ) have the power to take such action. SBP has a legal responsibility to arrange for the return to hospital of patients whose s.17 leave they have revoked. If resources are not provided to allow them to fulfil this legal responsibility, there is a risk that future patients, whose s.17 leave has been revoked and who remain at risk of self-harm or suicide whilst in the community, will find the opportunity to act in such a way as results in their death, whether intentionally or not. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 18 July 2019. I, the coroner, may extend the period.

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, 2019-0169

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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