Dad of Bristol woman dead from drug overdose "strongly dissatisfied" with coroner
Avon Coroners Court ruled there were no faults in the care of Evie Wilson, despite her dying whilst on forced leave from hospital
The dad of young Bristol woman Evangeline Wilson, who was found dead in her flat two years ago after being sent home on forced leave from hospital, says he is "strongly dissatisfied" with the conclusions of her inquest.
Then 24, Evangeline (known as Evie) died from a drug overdose while on leave from Cassel Hospital in London where she was being treated for severe mental health problems including bulimia, depression, self harm and attempts at suicide.
She was asked to temporarily leave the hospital just two days before being found dead, despite staff knowing she had recently self harmed, when she was found to have drunk a small bottle of vodka against site rules.
However, despite that and various other incidents that her dad says were failings in her care, last month a coroner at Avon Coroners Court concluded no changes in the hospital's procedures are necessary to prevent future deaths.
Dr Peter Harrowing also concluded we cannot be sure whether Evie would still be alive if she had been treated differently, or if she intended to take her own life when overdosing in July 2022.
Reflecting on the inquest Dr Nick Wilson, who is a GP, said: "In my opinion there are very strong messages that could be sent out to the organisations that were supposedly looking after Evie and the coroner has chosen to ignore all of that."
Evie's case
During the inquest into Evie's death we heard she had been suffering with severe mental health problems for several years, prior to being voluntarily admitted to Cassel Hospital.
By the age of 17 Evie was said to be in regular contact with her GP over issues of bulimia and self harm.
In 2017 she was admitted to A&E in Bristol seven times and in 2019 had to be admitted to hospital for five days in an attempt to break what was described as an "increasingly serious" cycle of self harming.
Evie was admitted to Cassel Hospital in June 2022 after three more years of similar behaviour, but was asked to leave temporarily after little more than two weeks, when she admitted drinking alcohol.
Despite telling staff she had self harmed the day before, she was sent home for a weekend on Friday 8th July.
To ensure her safety whilst at home a plan was drawn up that she would be contacted by mental health professionals from the Avon and Wiltshire Mental Health Partnership (AWP) on both the Saturday and Sunday, but neither contact was made.
She was found dead on the Sunday after Evie's mum raised concerns that she had not heard from her.
The coroner's conclusions & Dr Wilson's concerns
Despite Evie's long history of self harm, including an incident the day before she was asked to leave Cassel Hospital, coroner Dr Peter Harrowing concluded the West London NHS Trust (WLT) which runs Cassel, acted "essentially in line with the guidance" when asking Evie to leave.
It was also concluded that even if the planned welfare checks from AWP had taken place we cannot be sure Evie would still be alive, therefore a Prevention of Future Deaths Report, which would outline how a similar situation could be avoided in the future, is not needed.
Dr Wilson says those conclusions are not acceptable.
He said: "I have written to the coroner's senior to express my dissatisfaction...about the things I think went wrong.
"I've written to the senior coroner in the country with a copy of the letter I sent to the senior Avon coroner, expressing my dismay really, with what went on...
"I felt what happened can't just go uncommented on.
"I would hope that if enough people would continue to write about their experience, that maybe somebody would start to think things do need a review.
"I know I'm not the first person to comment on how the current coroner system has its shortcomings."
Dr Wilson says he is now fearful for other families with loved ones suffering in a similar way to Evie.
He said: "(I would be) extremely worried (for other families) yes.
"There was a very unrepentent team present at the inquest.
"They were present in force...the healthcare system is paying for these people, not to be looking after the patients in the unit, they're paying for them to come and sit in a court to defend their actions they took...
"The coroner very specifically asked the two key decision makers, would they make the same decisions again faced with the same circumstances and they both said absolutely yes they would have made the same decisions.
"So that says to me (that) there has been no learning at all."
Since Evie's death the WLT has introduced an assessment period for new patients at Cassel Hospital.
AWP also says it has conducted its own internal review, which it says identified a number of learning points.
We have contacted both WLT and AWP for comments.
Avon Coroners Court has declined to respond to Dr Wilson in public.