The death of a woman who took her own life after sharing a detailed suicide plan while sectioned on a mental health ward was contributed to by ‘systematic failures in her care’, an inquest has concluded. Louise Crane, 39, died on the Topaz Ward at Highgate Mental Health Centre in September 2024 while under the care of the North London NHS Foundation Trust.
On Tuesday (June 10), a jury at Bow Coroner’s Court in East London found factors contributing to Louise’s death were the suicide risk of her personality disorder in combination with unsatisfactory information sharing and recording, inadequate risk management, staffing, and levels of care and treatment from the Trust during her time on the ward.
Following the inquest, Louise’s family said: “We came into this inquest expecting to hear about some problems surrounding Louise’s treatment, but never did we expect the failings to be as bad as they were. We are shocked and horrified by the extent of the lack of care, leadership and professional responsibility, which was consistently demonstrated by the staff on Topaz Ward. Louise should have been kept safe and looked after in hospital but was not, and we believe that she has lost her life because of these failings.”
Louise’s ‘appalled’ family also hit out at the Trust’s ‘obstructive, evasive and shambolic’ approach, which, they say, sought to ‘minimise’ failures and avoid accountability for substandard care. The family also said it was especially upsetting to know Louise had shown positive signs of recovery ahead of her admission. “That hope has been taken from us,” they added.
Suicide threat not taken seriously enough
Ten witnesses gave evidence over seven days, revealing documentation of care was far below acceptable standards, with risk assessments only update twice and Louise treated as a ‘standard’ patient despite her well-documented struggles with Emotionally Unstable Personality Disorder.
Louise was stepped down to the acute ward on September 5 2024 at short notice, out of main staffing hours, and without an adequate handover, the inquest heard. Anxious about the move, Louise reported being unsettled, but jurors heard evidence that bed pressures meant the Trust could not deliver the structured step down she needed.
From September 12, Louise became withdrawn, spending more time in her room and refusing to engage with activities. Multiple witnesses conceded that record keeping fell below standard, directly leading to a loss of critical information about Louise’s risk to herself. The day before her death, Louise divulged a detailed plan to end her own life but it was never raised with the consultant psychiatrist.
An item mentioned by Louise was confiscated after she spoke about her plan, however no similar items were taken and a dangerous item used to end her own life was left behind. Despite the specific threat to end her life, she was kept on general observations, which only require one check per hour, compared to four for intermittent observations.
‘Sheer number of poor practices is disturbing’
Kim Vernal, representing the family, said: “The sheer number of poor practices revealed during Louise’s inquest is disturbing. This included deficiencies in information sharing, risk assessments, care and treatment, all stemming from poor leadership. The jury concluded that these deficiencies were contributing factors to Louise’s death.
“The very systems that should have been in place to protect Louise failed her when she was at her most vulnerable. It is imperative that the Trust reflect upon the jury findings and the Prevention of Future Deaths report HM Coroner will be issuing to ensure that the safety of other vulnerable patients is better protected in future.”
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