Fresh inquest starts into death of young woman refused hospital admission

The original 2015 inquest into the death of Sally Mays, 22, was quashed by the High Court last year.

Family handout of Sally Mays (Family/PA)

A new inquest will examine whether there was a “further missed opportunity” to prevent the death of a vulnerable young woman who killed herself after being refused admission to hospital, a coroner has said.

The original 2015 inquest into the death of Sally Mays, 22, was quashed by the High Court last year after the emergence of a conversation between one of Miss May’s care co-ordinators and a consultant psychiatrist on the day she died, which had been withheld from the original hearing.

Starting a fresh inquest on Monday, senior coroner Professor Paul Marks described how Miss Mays, who had long-standing mental health issues, died at home in Hull on July 25 2014 after she was turned away by the Humber NHS Foundation Trust crisis team earlier that day.

The coroner explained that these new proceedings would focus on the new evidence around the conversation in the car park between Laura Elliot, who had brought Ms Mays to hospital on July 25, and Dr Kwame Fofie, and that a transcript of the previous eight-day-long hearing would be read into the record.

He said he would have to decide whether anything in the car park conversation “represented a further missed opportunity to assess Miss Mays and admit her”.

Prof Marks told Hull Coroner’s Court: “I fully acknowledge that the family’s grief has been compounded and they have been unable to obtain closure.”

He began the proceedings by recapping his findings from the quashed 2015 inquest to provide background to the new evidence.

Reading from his 2015 narrative conclusion, the coroner said: “(Miss Mays) was inappropriately assessed, not treated with appropriate respect or dignity, was not reassessed after being restrained as she should have been or after showing increasingly worrying self-harming behaviour.

The failure to admit (Sally) to an inpatient psychiatric bed constitutes neglect and this neglect bears a direct causal relationship to her death later that evening

Coroner's 2015 narrative conclusion

“Had admission occurred after her initial assessment or following the further two missed opportunities, she would have survived and not died when she did.

“The failure to admit her to an inpatient psychiatric bed constitutes neglect and this neglect bears a direct causal relationship to her death later that evening.”

The coroner also recalled that he concluded “a further missed opportunity to save her life probably presented” when her call for an ambulance was not categorised appropriately and was compounded by delay in the arrival of paramedics.

Prof Marks said that, in 2015, he found that the assessment conducted by the gatekeeping nurse team was “lamentable” and the crisis team failed to identify the substantial risk of fatal self-harm.

The coroner said the decision not to admit Miss Mays was “illogical and unconscionable”.

Prof Marks said Miss Mays had long-standing psychiatric problems and was diagnosed with Borderline Personality Disorder.

Miss Mays’s parents, Andy and Angela Mays, from Hull, have spent years battling for a full investigation into their daughter’s death and their campaign culminated in the High Court ruling in December last year.

The High Court judges heard how Ms Elliot was leaving the unit that had refused admission when she spoke to Dr Fofie in the car park.

Bridget Dolan KC, representing her parents, told the High Court in written submissions that in one account of their exchange “Dr Fofie reassured her that ‘everything would be alright, and Sally would settle down or be picked up by a service’.”

She said that after Ms Elliot had discussions with two consultant psychiatrists, details of this conversation were not revealed to an internal NHS trust investigation nor the senior coroner.

Ms Dolan said Ms Elliot’s and Dr Fofie’s accounts of the conversation had changed over time, but said: “As the consultant psychiatrist to the admissions unit, Dr Fofie could have stepped in and reversed the unconscionable gatekeeping decision and averted Sally’s death.”

The inquest is expected to last three days.