Source · Prevention of Future Deaths

Cynthia Finlay

Ref: 2022-0138 Date: 11 May 2022 Coroner: Caroline Topping Area: Surrey Responses identified: 0 / 2 View PDF

There is no protocol for safeguarding at-risk individuals who are alone in the community while awaiting Mental Health Act assessments.

Date 11 May 2022
56-day deadline 6 Jul 2022
Responses identified 0 of 2
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Suicide (from 2015)

Coroner's concerns

AI summary
There is no protocol for safeguarding at-risk individuals who are alone in the community while awaiting Mental Health Act assessments.
View full coroner's concerns
(1) Expert evidence was received from a Consultant Psychiatrist who indicated that there is no protocol in place which governs what steps should be taken to safeguard people who are awaiting Mental Health Act assessments and may be alone and at risk in the community whilst the assessment is set up.

Report sections

Investigation and inquest
On 25th February 2021 an investigation was commenced into the death of Cynthia Elizabeth Finlay. The investigation concluded at the end of the inquest on 12th April 2022. The conclusion of the inquest was suicide, the cause of death being suspension.
Circumstances of the death
i.) Cynthia Elizabeth Finlay suffered from depression and had the onset of cognitive difficulties and personality traits which made her liable to be impulsive. It became impossible for her family to care for her.
ii.) On the 4th February 2021 she took an overdose and was admitted to hospital then discharged home on the 6th February 2021. She was living alone.
iii.) On the 8th February 2021 she was assessed by a community psychiatric nurse from the community mental health team who set up a further assessment for the following morning with a psychiatrist to consider whether a Mental Health Act assessment was warranted. One of her daughter’s attended the assessment.
iv.) On the 9th February 2021 she was assessed by the psychiatrist who did not accurately assess the risk of harm she posed to herself through her impulsivity and did not immediately initiate a Mental Health Act assessment.
v.) Her daughter, who was present, made it clear she could not stay with her Mother. No adequate plan was put in place to safeguard Ms Finlay.
vi.) Following the assessment, she was left alone. She in the garden at her home. She asphyxiated. She had written notes indicating an intention to take her own life.

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Report details

Reference
2022-0138
Date of report
11 May 2022
Coroner
Caroline Topping
Coroner area
Surrey

Responses identified

Responses identified 0 of 2
2 responses not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 6 Jul 2022.

Sent to

NHS England
Royal College of Psychiatrists

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