On 13 October 2021 I commenced an investigation into the death of Ms Aleksandra Markowska age 41 years. The investigation concluded at the end of the inquest on 27 September 2022. The conclusion of the inquest was a narrative conclusion:

Alexandra took her own life whilst suffering from pregnancy related depression and anxiety. She had suffered from severe symptoms for around four months. Despite seeking help from a number of sources she did not receive a review by a perinatal psychiatrist.

Between 17 June 2021 to the 21 July 2021 Alexandra had multiple contacts with the British Pregnancy Advisory Service (BPAS). She presented to the service with distress, agitation, anxiety and conflict over her pregnancy. On the 10 July 2021 a treatment unit manager identified a concern in relation to Alexandra's mental health and her mental capacity. The treatment unit manager considered that Alexandra required a mental health assessment. There was no direct access to a perinatal psychiatrist, so a safeguarding referral was made. The outcome of the referral is unknown. Alexandra did not undergo any review by a perinatal psychiatrist and she did not have a full capacity assessment undertaken. She expressed conflicting views about her pregnancy up until the termination of pregnancy took place on the 17 July 2021. On the 1 July 2021 Alexandra presented to her GP with anxiety, depression and insomnia relating to her pregnancy. She was referred to the mental health services and a review by a psychiatrist was requested. Alexandra did not receive an assessment by a psychiatrist. Within the mental health trust, Alexandra received contact from multiple teams but did not receive a full mental health assessment or a full assessment of her risk to self. There was an absence of joined up working and an absence of psychiatric attention. On the 30 September 2021 Alexandra was found unresponsive at the bottom of 21 Gardner Close, E11. Resuscitation was attempted by the emergency services, but sadly her life was pronounced extinct on scene. The evidence indicates that she had jumped Police found no evidence of third party involvement. There were no substances found on toxicology that would have impaired Alexandra's ability to form an intention to take her own life. A note had been sent indicating her intention to take her own life.