On 25 February 2015 commenced an investigation into the death of EMMA LOUISE BRAY age 25 years. The investigation concluded at the end of the inquest on 26 October 2015. The conclusion of the inquest was the medical cause of death of1a hanging and the conclusion that Emma Bray killed herself;, the requisite intention for suicide not being found.

Emma Bray ("EB") had a history of problems with mood dating back to her teens. In 2009 she received treatment for an impulsive overdose whilst under the influence of alcohol following a relationship breakdown: She had some contact with mental health services in 2011 and 2013. Towards the end of 2014 EB's mood declined, She had suffered a relationship breakup. Her mood became worse after Christmas. On 6 January 2015 EB was assessed by the Waltham Forest Access and Assessment Team Intake Team ("IT") . She gave details of her history and symptoms and told the social worker that she was on medication prescribed privately. She also told the social worker she was in the process of changing GP surgery The social worker discussed the case with a psychiatrist in the team and a decision was made to change the anti-depressant medication from Ecitalopram to Sertraline This recommendation was faxed to the GP The plan concluded "Emma to be considered for a brief allocation to monitor response to medication; ' A risk assessment was completed and recorded the risk of self-harm as low: The IT did not take steps to obtain EB's full medication either from her or her treating clinicians. No follow up telephone call or meeting was arranged. The referral to the Brief Intervention Team ("BIT") was not made, apparently because of workload. EB's parents then had contact with the IT on 19 January 2015 by telephone when some deterioration in her condition was reported. It was recorded that she would be discussed in the Intake meeting the following but this did not occur. EB's parents contacted the IT again on 22 January 2015 reporting that EB had no hope she would get better and was pleading with them to end her life_ When asked, the parents reported no known concrete plans to self-harm. This information was not placed before the IT MDT or passed on to anyone On 2 February 2015 EB's mother contacted the IT again: More details were obtained about EB's medication history and the social worker said that an appointment with a psychiatrist needed to be arranged . In the meantime the psychiatrist recommended that the dose of Sertraline be increased from 5Omg to 10Omg: On 11 February 2015 EB was seen at home by the social worker and psychiatrist Her parents reported concerns she would kill herself, They reported that she had been Policy history from day researching suicide on the internet but said she was not brave enough to do it Her risk assessment was updated and the risk of self harm was increased to moderate_ The Sertraline was changed from night to morning and the psychiatrist recorded different drug therapies he wished to consider The plan was for a doctor's appointment to review the medication ASAP , for there to be a referral to the psychology panel and for there to be a referral to BIT. psychology panel referral was made, although the panel that was due to sit on 16 February 2015 was cancelled and EB's case was delayed to the following week Neither the doctor's appointment nor the BIT referral were made. In the morning of 19 February 2015 EB's father emailed the social worker with a list of symptoms and concerns: "we are of course very concerned as she says she is not going to her life much longer like this. We also have concerns about her medication as things seem to be getting worse as the increased dose gets into her system"_ He emailed again at 15.08 on the same 'please call me as per last messagel met Emma lunchtime and she is completely withdrawn and unable to interact: know we have been needy but really must know what is happening and see Emma's health plan with dates. These emails were not entered into EB's notes or indeed ever provided by WFAAT. On the same EB's mother spoke to another member of the IT who spoke to the psychiatrist: He recommended an increase in the dose of Sertraline to 15Omy and to introduce Quetiapine_ In the early morning of 20 February 2015 EB's father emailed the social worker again informing her that EB had "gone down, down down to the nasty place. EB's mother spoke with the social worker that morning and was told that would have to wait for the medication to take effect: The plan recorded was for the social worker to refer to the BIT and tob Ifor EET advice On 23 February 2015 EB was discussed by the psychology On the same day the social worker referred EB to the BIT. On 25 February 2015 EB hanged herself:

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