Federica Cavenati
PFD Report
Historic (No Identified Response)
Ref: 2023-0410
No published response · Over 2 years old
Response Status
Responses
0 of 1
56-Day Deadline
20 Dec 2023
Over 2 years old — no identified published response
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
During the inquest, the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. The absence of intravenous anti-depressant medication for those in need, who cannot for physical reasons take the medication orally. The evidence I heard confirmed the existence of intravenous anti-depressants in Europe but not in the United Kingdom.
Report Sections
Investigation and Inquest
On 2 November 2021 an investigation commenced into the death of Federica Cavenati, aged 28 years. The investigation concluded at the end of the inquest on 9 October 2023. The conclusion of the inquest was that Federica Cavenati did the act of jumping
, London with the intention of taking her own life, which was more than minimally contributed to by service delivery issues, including that she had not taken consistent antidepressant medication for some time since her admission due to her physical condition, arising from an act of self-harm; drinking oven cleaner. The medical cause of death was 1a multiple traumatic injuries and 1b fall from height.
, London with the intention of taking her own life, which was more than minimally contributed to by service delivery issues, including that she had not taken consistent antidepressant medication for some time since her admission due to her physical condition, arising from an act of self-harm; drinking oven cleaner. The medical cause of death was 1a multiple traumatic injuries and 1b fall from height.
Circumstances of the Death
On 12 September 2021 Federica Cavenati cause herself harm. She was admitted to the Chelsea and Westminster Hospital where she was treated for her physical and mental health on a medical ward. She had previously been prescribed anti-depressant medication, however due to her physical health and the unavailability of anti-depressant medication intravenously, she did not receive this medication until she was physically able to, which was shortly before her death. Her 1:1 mental health nursing observation was removed on 17 September 2021. Her last review by the Psychiatry Liaison Team was on 17 October 2021 with no further review taking place. On 15 October 2021 she refused her blood line. On 16 October 2021 she refused her medication (including Ensure supplement) and again on 17 October 2021. On 18 October 2021 she was found
. She sustained multiple traumatic injuries resulting her in death on 18 October 2021. The following factors contributed more than minimally to her death:
1. She had not had a recent mental health review.
2. There were no mental health observations.
3. She had not taken consistent anti-depressant medication for some time.
. She sustained multiple traumatic injuries resulting her in death on 18 October 2021. The following factors contributed more than minimally to her death:
1. She had not had a recent mental health review.
2. There were no mental health observations.
3. She had not taken consistent anti-depressant medication for some time.
Similar PFD Reports
Reports sharing organisations, categories, or themes with this PFD
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Independent review of use of force on mentally ill detainees
Brook House Inquiry
Mental health access for alcohol addiction
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.