Cannot be sure Bristol woman took own life while on hospital leave, Coroner rules
24-year-old Evie Wilson died from a drug overdose in 2022
Last updated 15th Mar 2024
A coroner has ruled we cannot know for sure whether a Bristol woman intended to take her own life, while on leave from a mental health unit.
Evie Wilson who was 24 died on 10 July 2022 while on forced weekend leave from Cassel Hospital in London, after staff discovered she had been drinking alcohol to manage distress.
She had been undergoing residential treatment at the hospital following a complex history of mental health problems including bulimia, depression, severe self-harm, suicide attempts and post-traumatic stress disorder.
However, after admitting drinking a small bottle of vodka against hospital rules, she was asked to go home.
Two days later she was found dead in her flat.
Evie's care
Whilst at Cassel Hospital, Evie was under the joint care of hospital staff, but also the Avon and Wiltshire Mental Health Partnership NHS Trust (AWP).
When asked to leave the hospital on 8 July (a Friday) an email was sent to the AWP team advising them on the situation, but no one checked whether social support would be available for her that weekend.
The email was seen by her Consultant at AWP who put in place a safety plan for the weekend but despite that no one contacted her, before she was found dead on the Sunday.
The plan was as follows:
- Duty team to contact Evie by telephone on the Saturday and Sunday
- Crisis Team to be made aware that she had been sent home
- The Psychiatric Liaison Team to be made aware in case she presented at A&E
- A follow up on 11 July to discuss Evie’s care and arrange for her Care Coordinator to contact her
Welfare checks were supposed to take place on both Saturday and Sunday, but during proceedings at Avon Coroners Court we heard the Saturday check did not take place because the staff member who should have carried it out, was sick.
Sunday's check also did not take place, though the reason for that one being missed has not been established.
The coroner's conclusions
Summing up proceedings in court today (15 March) the coroner Dr Peter Harrowing ruled we cannot be sure that Evie intended to take her own life, when she took a drug overdose that weekend.
He also ruled "we cannot know" whether Evie would still be alive had the welfare checks been carried out and he said based on the evidence, asking Evie to temporarily leave Cassel Hospital was justified.
The process followed which resulted in Evie being granted short leave was followed, "essentially in line with guidance," he said.
Prior to the leave being granted doctors testified that Evie had told them she did not intend to harm herself and so they considered her not to be at immediate risk.
It was also mentioned in evidence however, that the day before being given short leave, Evie had admitted self harming.
Continuing to discuss the missed welfare checks, Dr Harrowing concluded that by the rule of law they did not deny Evie potentially life saving treatment.
This is because, he said, the checks were only requested on a precautionary basis and not because Evie was considered an immediate risk to herself.
A Report to Prevent Future Deaths, Dr Harrowing ruled, is not necessary.