“The inquest heard that discharge planning including communication with GPs and families…”

The coroner’s concerns

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- 1.The inquest heard that discharge planning including communication with GPs and families around risk was not effective. Key information was not shared with the GP or the family particularly when care moved back to the family; 2. There was no clear evidence of consideration of discharge medication and risk around prescribing of medication post discharge from the EDU. | As a result Hannah was prescribed a month's supply of medication; | 3. The suitability of acute mental health beds for young adults and lack of alternative provision The inquest heard that Hannah went to an acute adult psychiatric bed because the EDU felt that it was the wrong environment for her and there was no other alternative. The inquest heard that there were concerns regarding the placement of a young adult in such a setting and how frightening it was to her; 4. Communication with private providers by NHS trusts once mental health trusts have placed individuals in private settings. During the time that Hannah was placed at the Priory the mental health trust who placed her did not have any discussion with Hannah, her family or the Priory regarding the placement. A care coordinator had been allocated by the Trust once requested by the Priory but no care coordination had taken place; 5.The expectations around information sharing with private providers and the expectation on private providers contracted by the NHS to seek information. The Priory did not request any notes from the EDU about Hannah. As a result they were unaware of detailed information held by the Trust regarding previously expressed suicidal ideation; 6. Understanding and communication by the Priory about the change in risk level when Hannah moved from a secure environment to periods of time outside the unit in the care of her family; 7. The inquest was told by the clinical lead for Eating Disorders of the high risk of Eating Disorders in high achieving students on courses such as medicine. In such cases, the inquest was told universities need to be alert to early signs of anxiety that risk leading to eating disorders developing, As part of this understanding by universities the inquest was told of the need to recognise early signs of mental health issues and listen carefully from an early stage. The skill set/training of academics in welfare roles in relation to mental health was described as key and ‘specific work with Eating Disorder services and training of those involved | in welfare programmes supporting students can be effective; 8. The guidance in relation to the height of glass balustrades where items such as tables, in cafes open to the public including children and other vulnerable people, are placed in close proximity to the glass. The glass balustrade in John Lewis was at a height that accorded with the required standard but by simply climbing onto the table that was adjacent to the balustrade Hannah was able to easily go over the balustrade.

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, 2019-0254

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