On the 25th April 2016 commenced an investigation into the death of Rachel Morgan The investigation concluded on the 9ih February 2017 ad the conclusion reached by the was one of Suicide with an appended Narrative. The medical cause of death was Ia) Severe anoxic brain injury:

Prior to the birth of her second baby; Rachel was healthy; did not Iike taking medication and had no previous mental health issues: After the birth she became Increasingly unwell with fluctuating moods and emotlons, which led to her seeking medical help. She made two suicide attempts, after which she was admitted to hospltal. After each admission she was discharged under the care of home-based communlty teams: She was diagnosed with post-natal depression with psychotlc symptoms, which gradually worsened; with some fluctuations. Rachel had fears of harm coming to her baby but became increasingly detached from her; though there was no concern that she was a threat to her children: The mother and baby unit was discussed on several occasions wlth one referral put on hold awaiting a multi-discipllnary team meeting: Immediately to her admlssion In April, her partner and mother did not feel could keep her safe In the community: Rachel attended an outpatient's appointment on the 12th April t0 review her medications. Durlng this appointment; the clinician's ongoing concerns were heightened by the knowledge that she had been orderlng drugs on the internet to end her Ilfe. Rachel did not want to be admitted to hospital so went home; where she was restralned until professionals arrived. She was taken to hospital under an emergency section 4 of the mental health act due to the unavailabllity of a second opinlon doctor at that tlme: The approved mental health professional provided a verbal handover to the ward staff, highlighting Rachel"s history and her current high risk: There were contradictory accounts of the content of the handover and there were possible omissions In the handover which were not fully documented: Rachel was admitted to the ward by a section 12 doctor observed by the clerking doctor. A risk assessment was completed by nursing staff who Initially put her on amber risk of suicide; which was updated to red soon thereafter: She was on level three observations and allocated a primary nurse who was on nights. During her time on the ward;, she was assessed to be engaging and talking to staff but had constant thoughts to end her life: Concerns were ralsed by nursing staff about her preoccupation with a Nicorette Inhalator, concerns which were recorded on the PARIS system but were not Included In an updated risk assessment were not shared wlth doctors prlor to the ward round, On the 15th April the famlly highilghted specific concerns regarding Rachel s safety which were discussed by nursing staff; updated on the PARIS records but were not added to the risk assessment: The levels of observation were not raised: Despite Rachel's and her familys repeated requests to revlew and change her medication, this was continually delayed and no immedlate actlon was taken: Rachel was found at approximately 10.20am on I6th April 2016 In room 7 of the Medlock ward, Moorside unlt: Jury prior - they put They

Four nurses attempted to open the door to Rachel s room, one of whom entered to find Rachel slumped behind the door with a llgature around her neck A crash team and ambulance staff were called and CPR was commenced. Rachel was transferred to Salford Royal Hospital at approximately 11.20am ad died from severe anoxic brain Injury on 24th Aprll 2016. The Jury concluded that Rachel died as a result of suicide and recorded the following narrative conclusion: Suicide and Narrative: The level of observatlons on the Rachel was admitted were Insufflclent: The Trust has accepted that on 12th April the level of observations should have been considered on admission and a decision to place Rachel on enhanced observations would not have been unreasonable: The Information relating to Rachel's conversation with the nurse on 14th April regarding the Nicorette Inhalator should have been handed over to the cliniclans conducting the ward round on 15th April: It Is possible that had this Information been avallable_the clinlclan may have altered the level of observations. The Information from during her telephone call to the Medlock ward on the evening of 15th Aprll should have led to a change In Rachel's level of observations: We consider that level would have been appropriate: The failure to put Rachel on level observations probably contributed to death, as it provlded her wlth the opportunity to end her Ilfe: The trust accepts that on the 15th April 2016 staff could have consldered level 2 observatlons as a mlnlmum following Rachel's mother telephoning the ward with her concerns. The Trust also accepts that the risk assessment documentation should have been updated to Include the new information provided by Rachel's mother; the discussion which took place with Rachel ad the reasons for the staff not Increasing levels of observatlons. It Is more than Ilkely that the In revlewing Rachel's medicatlon contributed to her Increased hopelessness and risk of suicide_

In my opinion action should be taken t0 prevent future deaths and believe you have the power to take such action: