Dorota Kijowska

On 15 March 2016, reopened the inquest touching upon the death of Dorota Agnieszka Kijowska: sat with a jury and on 17 March the jury recorded the following conclusions:- On 23 March 2015, at approximately 16.1Opm Dorota Agnieszka Kijowska was found hanging by a scarf from an unsecured loft hatch in a toilet cubicle at Gosfield ward the Lakes Colchester: Resuscitation attempts were unsuccessful and she was pronounced dead at 17.1Opm: Dorota Agnieszka Kijowska killed herself. Based on the evidence provided, the have concluded that there was a failure to provide a safe environment at the unit and this, in conjunction with ineffective communication, more than minimally contributed to her death.

Please see jury's findings above: She had been an informal patient at the Lakes Mental Health Unit from 10 March 2015 and she returned from weekend leave at 8am on Monday 23 March 2015. At a review held that day, Dorota expressed threats to harm herself and the plan to give her a further period of home leave appears to have been changed: This was not relayed effectively to Dorota who was found hanging later in the afternoon:

In my opinion action should be taken to prevent future deaths and believe your organisation have the power to take such action: Such important decisions must be agreed by all those present and signed off in writing so that there is no confusion as to the outcome of the review: Your RESPONSE You are under a duty to respond to this report within 56 of the date of this report; namely by 23" 2016. 4, the coroner; may extend the period. Your response must contain details of action taken or proposed to be taken; setting out the timetable for action: Otherwise you must explain why no action is proposed.