On the 5 December 2016, I commenced an investigation into the death of the late Ms Abigail Baynham. The investigation concluded at the end of the inquest on 27 February 2017. The conclusion of the inquest was a short narrative conclusion of suicide.

The cause of death was:

1a Hanging

i) Ms Baynham had been known to Mental Health Services since 2010 with suicidal ideation precipitated by varying factors including illicit drug use, alcohol use, post-natal depression, relationship difficulties and social circumstances. ii) She had been referred by her GP to Healthy Minds in September 2016. The patient did not attend two appointments with Healthy Minds, had not responded to further contact attempts and was therefore discharged back to the care of her GP. iii) She was admitted to New Cross Hospital, Wolverhampton on 20th November 2016 following an overdose of paracetamol, Ibuprofen and fluoxetine. Following the overdose, the patient was assessed by a Senior Nurse Practitioner within the Mental Health Liaison Service (MHLS) on 22nd November 2016. Although initially reluctant to engage she did cooperate with the assessment which did not, at the time, identify delusional thinking, paranoid ideation, perceptual disturbances or psychosis. This, together with the patient having capacity to make decisions regarding her care meant she was not detainable under the Mental Health Act. iv) At the time, she was offered appropriate services that correlated with the outcome of the assessment. The patient declined further support from Mental Health services although the patient was made aware that she could

[IL1: PROTECT] change her mind if she wishes to access support in the future and was given the number for Penn Hospital. v) Later in the afternoon she left the hospital taking her belongings and stated she no longer wishes to be there. The Police and family were notified and later that day she returned home with her family. vi) Sadly, on the 29 November 2017 she was found deceased at her flat and had taken her own life.

1. You may wish to consider setting up a protocol for referral to Mental Health Liaison Service in this situation when a patient absconds from hospital.