“When planning for Ms Beavington’s discharge from hospital, it was agreed that the best…”
Dated 20 Feb 2025, from the coroner for Inner North London. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 17 Apr 2025.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated20 Feb 2025
- Deadline17 Apr 2025
- Published on judiciary.uk25 Feb 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| North London NHS Foundation Trust | Response publishedPublished on judiciary.uk in February 2025. |
The coroner’s concerns
When planning for Ms Beavington’s discharge from hospital, it was agreed that the best place for her to go was a local crisis house. Upon application, the foundation year 1 doctor (FY1) was told by the crisis house team that this was not possible because: Ms Beavington had secure accommodation; and she was no longer actively suicidal. This was despite the fact that: there was a strong suspicion that Ms Beavington was the victim of cuckooing in her own home; and the team view was that she was definitely at risk of suicide. The consultant psychiatrist in charge of Ms Beavington’s care did not give the FY1 any instruction as to how to challenge the decision that the consultant believed was wrong. Instead, the consultant instructed the FY1 to leave it for three days and then just try again in the same way. By this time, Ms Beavington decided that she had waited too long and did not want another attempt to be made. Ms Beavington was discharged home and killed herself at 1am the next morning.
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, 2025-0097
- Added to Minute Book
- 8 Oct 2026
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- We show short extracts and link to the original. We don’t host the full report.
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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
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