An investigation into the death of Anne Morris commenced on the 28/6/2017. The investigation concluded at the end of the inquest on 2nd November 2017 . The conclusion of the inquest was that the medical cause of death was 1(a) hanging: The short form conclusion was "Suicide"

1) On the 26/6/2017 Anne hanged herself whilst she was alone inside the house of a friend in Merryfield Road Eltham had secured the house from the inside and her friend had to gain access by a ladder to an upstairs room left a handwritten message expressing that her life had been "ruined" by financial debts caused by a former partner and apologising to her friend,
2) The inquest heard evidence that on the 8th May 2017 Anne had become very distressed by a solicitors' letter claiming substantial legal fees, dating back to 2010, which had been unpaid by her ex-cohabiting and business partner
3) On the 9/6/2017 after taking an overdose of paracetamol tablets she was visited by the Lewisham Home Treatment (psychiatric) Team (Oxleas HTT) on the 10/6/17 and was voluntarily admitted to hospital by the Oxleas NHS Foundation Trust (Oxleas) . Oxleas covered the Eltham area. Anne's usual address was in Surbiton prior to her temporary stay in Eltham.
4) Due to a shortage of psychiatric beds she was placed by Oxleas in the Hospital Ticehurst House in Sussex, which is a private hospital, and was discharged to her friends address in Eltham on the 23/6/17.
5) During the inquest read the evidence ofl a consultant Psychiatrist at the Hospital, who recorded that prior to Anne's discharge from hospital she consented to staff speaking to her brother] and Peter Forrester who provided her accommodation in Eltham. She She Priory Priory candidly noted in his report that there was no record of any staff contacting Anne's friend or her brother prior t0 discharge_ On the 25/8/17 Anne was seen by the Oxleas HTT at the Eltham address_ The Oxleas HTT did not have the benefit of a discharge plan from the Hospital:
8) In a Root Cause Analysis report provided by Oxleas NHS Trust it was recorded that as "AM approached her discharge from Ticehurst Priory, there is no evidence of forward discharge planning with the community team to whom care was transferred or the address where AM would be staying and therefore which team would be responsible for her follow up'
9) During the inquest both] and indicated to me their concerns that were not contacted by the mental health services prior to Anne's discharge from hospital to discuss her care in the community.
10) At theendofuthe inquest indicated to the representative for Oxleas_ and that was considering making a regulation 28 report but before doing so would be assisted by written representation from Oxleas concerning what had been done by Oxleas since the death to address the problems concerning discharge from hospital in the RCA report gave Oxleas 14and dys to respond and then a further 14 days for provide written observations on the Oxleas response
11) The response from Oxleas 13/11/17 (received 23/11/17) , identified the following recommendations and progress: GP records must be requested by the Greenwich Home Treatment Team when an unknown out of area patient is referred to the service_ Clinical documentation must be updated and in a timely manner:
12) In responses received from both expressed concerns that neither of them had been contacted by the Priory hospital staff prior to Anne's discharge and that Anne's indication that she was willing for staff to contact them both had not been communicated to the community HTT. In the case ofl hhe expressed the opinion that if the mental health services had contacted him he would have been more aware of the risk Anne presented to herself and he might have been able to help avert the tragedy:

In my opinion action should be taken to prevent future deaths and believe your organisations have the power to take the following action: The Priory Hospital should indicate what steps have been taken since the death to ensure that where a patient has given consent to staff contact named friends and relatives in the community that efforts should be made to consult those individuals when preparing a discharge plan_ The Priory Hospital should indicate what steps have been taken since the death to ensure a system of promptly issuing care plans prior to discharge into the community including contact details of friends and next of kin where the patient consents to contact with named individuals_ The Hospital should indicate what steps have been taken since the death to ensure that the responsible HTT for the area in which the patient will be is contacted directly and that such contact is confirmed by a response from the relevant HTT_ Oxleas HTT should indicate what steps have been taken since the death to ensure a system of liaising with the discharging hospital in situations where have not been provided with a discharge plan in order to obtain the same or to urgently formulate one with the discharging hospital: