On the 23r November 2015 [ commenced an investigation into the death of Joanne Michelle French (otherwise known as Joanne Michelle Hay), years_ The investigation concluded at the end of the inquest on December 2015. The conclusion of the inquest was suicide and the medical cause of death was [a) hanging: The short form conclusion of suicide was supplemented by a narrative conclusion in the following terms Joanne French made a serious attempt on her life on the 2"d December 2014 by throat. She waS taken to hospital where she was treated for her injury: She was admitted voluntarily to the psychiatric ward at Meadowfield Hospital on 3rd December 2014. She was discharged from that ward on the [th December 2014. There were communication errors made in the assessment and decision process for her discharge which related t0 obtaining views of members of Joanne '$ family and the accuracy of information recorded as provided by the family: Had those communication errors not existed, it is likely that Joanne would not aged cutting her making being have been discharged on the [* December 2014

1) Joanne French first went to see her GP concerning depression in September 2014 Her GP prescribed anti-depressants She had no history of depressive illness .
2) On the 2nd November 2014 she suffered a form f breakdown which resulted in her family taking her to A and E at the Royal Sussex County Hospital. She was not admitted to hospital on that occasion but it mark the start of her engagement with the Crisis Resolution Home Treatment Team. She was seen at home daily by that team, with slightly reduced contact towards the end of the first month Joanne French was seen on the December 2014 by a psychiatrist with the Crisis who altered her medication as she was not showing the anticipated improvement:
4) Without any obvious warning signs, Joanne made a significant attempt on her life on the 2"d December 2014, cutting her throat and narrowly missing major arteries She was admitted to the Royal Sussex County Hospital and then to Meadowfield Hospital: It was not necessary for a decision to be made to detain her under the Mental Health Act as Joanne agreed to voluntary admission.
5) Joanne French was discharged from Meadowfield Hospital on the 11th December 2014, which the Psychiatrist making the decision to discharge her described as an 'exceptional course'. The Psychiatrist gave evidence to the effect that he expected the family's views to be canvassed in the discharge assessment and that his decision on supported discharge would be influenced by the family's views. The importance of that aspect of the assessment to the decision maker was not understood or communicated t0 the nurse carrying out the assessment for discharge. Although the nurse carrying out the assessment prior did Team spoke over the telephone tol Joanne's husband) at some point during the assessment process, she did not specifically ask his views and the discussion was in presence of Joanne French: The nurse conducting the assessment was unaware that the psychiatrist who would be making the discharge decision specifically wanted to know the family's views_ psychiatrist believed that before making the discharge decision he had spoken directly to the nurse undertaking the assessment of Joanne for suitability for discharge but that was disputed by the nurse who undertook the assessment. She denied speaking directly to him and said he was not at the ward at the time The psychiatrist was therefore reliant on the written notes of that assessment. The notes made of the assessment were inaccurate in that they reported views when in fact those were the views of the patient: Joanne's husband and twin sister were taken by surprise with the decision for her early discharge. were not aware that the person who would make the decision as to discharge wanted their imput: They had no experience of the procedure and did not understand that their views were relevant to the discharge process, the discharge being presented as a foregone decision. had made an arrangement to discuss Joanne French's condition with the psychiatrist on the morning of 12th December 2014 but in light of her early discharge, that appointment never took place.
10) In the early hours of the morning on 14th December 2014 Joanne French was found by a passer-by at Southwick Recreational Ground to be hanging by a scarf attached to her neck and a climbing frame. Emergency Services were called and CPR commenced on their arrival. She was unable to be revived and was transferred to Royal Sussex County Hospital where she was formally pronounced to have died. the The They

In my opinion action should be taken to prevent future deaths and believe your organisation has the power to take such action.