Cynthia Finlay
PFD Report
Historic (No Identified Response)
Ref: 2022-0138
Coroner's Concerns (AI summary)
There is no protocol for safeguarding at-risk individuals who are alone in the community while awaiting Mental Health Act assessments.
View full coroner's concerns
(1) Expert evidence was received from a Consultant Psychiatrist who indicated that there is no protocol in place which governs what steps should be taken to safeguard people who are awaiting Mental Health Act assessments and may be alone and at risk in the community whilst the assessment is set up.
Sent To
- NHS England
- Royal College of Psychiatrists
Response Status
Linked responses
0 of 2
56-Day Deadline
6 Jul 2022
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 25th February 2021 an investigation was commenced into the death of Cynthia Elizabeth Finlay. The investigation concluded at the end of the inquest on 12th April 2022. The conclusion of the inquest was suicide, the cause of death being suspension.
Circumstances of the Death
i.) Cynthia Elizabeth Finlay suffered from depression and had the onset of cognitive difficulties and personality traits which made her liable to be impulsive. It became impossible for her family to care for her.
ii.) On the 4th February 2021 she took an overdose and was admitted to hospital then discharged home on the 6th February 2021. She was living alone.
iii.) On the 8th February 2021 she was assessed by a community psychiatric nurse from the community mental health team who set up a further assessment for the following morning with a psychiatrist to consider whether a Mental Health Act assessment was warranted. One of her daughter’s attended the assessment.
iv.) On the 9th February 2021 she was assessed by the psychiatrist who did not accurately assess the risk of harm she posed to herself through her impulsivity and did not immediately initiate a Mental Health Act assessment.
v.) Her daughter, who was present, made it clear she could not stay with her Mother. No adequate plan was put in place to safeguard Ms Finlay.
vi.) Following the assessment, she was left alone. She in the garden at her home. She asphyxiated. She had written notes indicating an intention to take her own life.
ii.) On the 4th February 2021 she took an overdose and was admitted to hospital then discharged home on the 6th February 2021. She was living alone.
iii.) On the 8th February 2021 she was assessed by a community psychiatric nurse from the community mental health team who set up a further assessment for the following morning with a psychiatrist to consider whether a Mental Health Act assessment was warranted. One of her daughter’s attended the assessment.
iv.) On the 9th February 2021 she was assessed by the psychiatrist who did not accurately assess the risk of harm she posed to herself through her impulsivity and did not immediately initiate a Mental Health Act assessment.
v.) Her daughter, who was present, made it clear she could not stay with her Mother. No adequate plan was put in place to safeguard Ms Finlay.
vi.) Following the assessment, she was left alone. She in the garden at her home. She asphyxiated. She had written notes indicating an intention to take her own life.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.