On the 22nd February 2018 commenced an investigation into the death of Samantha Louise Higgins _ The investigation concluded at the end of the Inquest on the 2oth November 2019, The conclusion of the Inquest was a narrative conclusion: Sammi Higgins suffered from emotionally unstable personality disorder; anxiety, depression and mood congruent psychosis: Her mental state had been deteriorating over the 10 months leading up to her death. Her presentation was characterized by overwhelming voices Sammi to harm herself. Sammi was under the mental health services throughout this period of time, but no overarching care plan was in place and she had no key-worker assigned to her. There was no assigned member of the mental health team with responsibility to ensure that Sammi's care plan was actioned. Sammi was deemed to be at moderate to high risk of suicide in early January 2018 was considered that her anti-psychotic medication needed to be changed as & priority: The change of medication was not communicated to the GP and no steps were taken to ensure that the medication change took place: On Friday the znd February 2018, Sammi presented to the mental health team after taking an overdose of medication and self-harming by cutting: She was deemed to be a low risk of suicide by the assessing nurses and discharged home with no mental health support offered over the weekend. On Saturday 34 February 2018 Sammi ingested a fatal combination of alcohol and tablets. Sammi took the action that lead to her death. Her intention at the time of this action is unknown due to the effect of the overwhelming voices upon her ability to form an intention.

See above narrative conclusion.

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action: