Earlier this week, the Divisional Court in London ruled a new inquest should be held after the death of Sally Mays, in 2014.  In 2015 the original inquest returned an extremely critical verdict amounting to neglect by Humber Teaching Foundation NHS (mental health) Trust which led to Sally’s death and it has now emerged relevant information was withheld from the inquest, in particular concerning a conversation between nurses who dealt with Sally and a consultant psychiatrist.Sally presented to a mental health unit in Hull in 2014 in a condition of some distress, seeking help and support from the services there.  The two nurses from a CrisisTeam who saw Sally declined to admit her to the hospital and the police were called.  Officers ended up having what the Humberside Senior Coroner described as a “stand up fight” with the nurses, because they shared Sally’s own concerns about the circumstances and her mental well-being.  Having been unable to persuade a different course, officers brought Sally away with them and reluctantly walked away.  They took Sally home, did the best they could and she subsequently died by suicide, not helped by a delay in the ambulance response when she was found.

In a blog on the Serjeant’s Inn website, Emily Chappell noted “the Senior Coroner was excoriating in his criticisms of the refusal to admit Sally, describing it as an “illogical, quixotic and unconscionable decision’. There had been an “inappropriate pre-determination not to offer admission to Sally” by the gate-keeping nurses and that mandatory assessment by a medical practitioner had not been requested.  Further, the process had itself caused Sally additional harm.  The Senior Coroner found, that the refusal of admission was  “provocative and escalated Sally’s distress and contributed to her reactive self-harming behaviour”.  These were “gross failings in her management” when Sally would probably not have died had she been admitted to hospital. The Coroner recorded that Sally had died as a result of neglect, noting that there had been a number of missed opportunities to prevent Sally’s death.

I won’t cover much of the other detail in the blog, but I do encourage you to read it because it has now emerged in documents presented to the Divisional Court that one of the nurses had discussion with a senior psychiatrist in a car park after the police had left.  The Court stated this week, it was “clear” from those documents that a “conscious decision” was taken “both before and during the inquest to withhold information about the car park conversation” and a fresh inquest would allow that to take place.

I’ve spent today wondering and worrying about the impact of this ongoing process and campaigning on Sally’s parents, Angela and Alan Mays as well as her brother Ben who is a paramedic and must see things in his work which cause him to constantly reflect on all this, working alongside other services and dealing with similar incidents.  We know the impact of living with and chipping away against injustice can be significant and this family are now seven years in to their nightmare, but in fairness to them: Sally herself did warn services before her death that if anything happened to her, they’d have to deal with her mother.  Angela’s campaigning continues and has always been deeply, if quietly impressive.  I’d hope to have even half the resilience and fortitude that I sense from her Twitter feed if faced with similar, devastating circumstances.  To find, as they did this week, that professionals under oath in court did not tell the WHOLE truth, given the oath and affirmation which is sworn by all witnesses is something I note for what it obviously may be worth.

It links to duties to the duty of candour in the NHS and I admit to being very interested to see how this new evidence will be considered at some point next year.  Mostly, though, I wish them well in continuing to deal with this and hope it doesn’t demand too great a toll from them.

Winner of the President’s Medal,
the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award

All views expressed are my own – they do not represent the views of any organisation.
(c) Michael Brown, 2021

I try to keep this blog up to date, but inevitably over time, amendments to the law as well as court rulings and other findings from inquests and complaints processes mean it is difficult to ensure all the articles and pages remain current.  Please ensure you check all legal issues in particular and take appropriate professional advice where necessary.

Government legislation website – www.legislation.gov.uk