A hospital 'missed an opportunity' to establish a Harrogate woman's psychological history and refer her to a mental health team before her death, an inquest today heard. 

The two-day inquest into the death of Ellen Francesca Anderson, who was just 26 when she died last year, concluded at Northallerton coroners court today.

Ms Anderson took her own life after running away from Harrogate District Hospital, where she had been taken by her mother just hours before, following an attempted overdose.

The 26-year-old, who had a young son, had an “argument with her partner” the night before her death, Coroner Catherine Cundy said, adding her partner left their house as a result.

Ms Anderson, who worked as a Post Office clerk, consumed a mixture of medication and alcohol, then made a “distraught” call to her mother, the court heard.

The Stray Ferret yesterday reported a named nurse, who gave evidence in court, undertook Ms Anderson’s triage assessment shortly after she arrived at the hospital at 4.45am, on June 30, 2023. 

This was to ascertain the level of priority Ms Anderson should be given for treatment.

The nurse, who had been working at the hospital for 18 years at the time, concluded Ms Anderson was of category three risk and a “moderate risk of self-harm”.

This means she was not required to receive urgent medical treatment, but should have been seen within an hour of the assessment being completed.

But the court also heard the nurse “could not recall” asking Ms Anderson, or her mother, whether she had any history with mental health, and that the nurse "did not have access" to an online software used to store medical records at the time. This meant she did not have access to Ms Anderson's records.

The nurse also said she did not feel Ms Anderson was at risk of harming herself further and did not refer her to the mental health team at the time. 

However, the court today heard Ms Anderson had a history of anxiety, depression and self-harm since the age of 11.

Coroner Catherine Cundy also said she previously had counselling sessions and took anti-depressants, adding she had even been seen by the Crisis team aged 15 following an attempted overdose and “suicidal thoughts”.

Just a day prior to her death, Ms Anderson had an online appointment with a private consultant psychiatrist to see if she displayed symptoms of ADHD.

Ms Cundy told the court during her assessment, Ms Anderson said she was “not helped by any medication she had previously taken”.

The court heard Ms Anderson also told the consultant:

Ms Anderson had experienced intense and dysregulated emotions since childhood, Ms Cundy told the court, adding she became “overwhelmed” by her emotions and had a fear of abandonment.

The court heard the consultant found Ms Anderson displayed symptoms of ADHD. She agreed to "look into" medication and therapy, the coroner said. 

Mental health assessment form ‘not completed’

Around the time of the triage assessment, the nurse was also supposed to complete a mental health initial risk assessment form.

Ms Cundy said, in this instance, the purpose of the form was to “establish significant information to determine the patient’s pathway”, adding it was also required to make a referral to the mental health liaison team.

However, the court heard the form was “not fully completed”, nor was it completed in the presence of Ms Anderson or her mother.

The coroner said:

The court also heard several medical professionals believed Ms Anderson “had capacity”. 

Dr Earl, deputy medical director at the hospital, yesterday defined capacity as patients understanding the implications of leaving the hospital willingly before being assessed.

There was "nothing that made us think she lacked capacity", he told the court. 

Ms Anderson was then placed in a cubicle to “sober up and sleep”, but she was never assessed by a doctor or referred to the mental health team.  

Ms Cundy said:

The coroner accepted the emergency department was “very busy” that night – addressing “staff pressures” – but added the incomplete form “represented a missed opportunity to establish Ellen’s psychological history”.

There was also a missed opportunity to start the process of referring Ms Anderson to the mental health liaison team, Ms Cundy added. 

Absconds from the hospital

The court then heard Ms Anderson and her mother had gone outside for a cigarette, before returning to the emergency department.

However, shortly after Ms Anderson fled the hospital. Her mother reported this to a nurse at around 7am, who called the police.

The court yesterday heard a police dispatcher declined to assist in searching for Ms Anderson – which Ms Cundy concluded is “not uncommon” – and allegedly told the nurse to “send for an ambulance” despite not knowing where Ms Anderson was.

Ms Cundy said this was a “pointless and illogical” response, but added the police did not have any evidence to suggest Ms Anderson would harm herself.

Ms Anderson answered a call from a nurse, the court heard, at which point she said she did not know where she was and “did not want to be here anymore”.

Ms Cundy added:

At this point, the court heard, a nurse made another call to the police, who deployed officers soon after.

However, Ms Anderson “threw away her phone” and “ran to a wooded area in Harrogate”.

It was there that she took her own life and was later found by a member of the public. 

Ms Anderson was pronounced dead at the scene at 9.33am.  

‘Just want to feel peace’

The court heard a toxicology report found “therapeutic” levels of medication and alcohol in Ms Anderson’s blood, but these did not contribute to her medical cause of death.

Ms Anderson left three letters in a drawer at her home, Ms Cundy said, adding these were “not dated” but were “farewell letters”.

The coroner read part of a letter, addressed to her parents, which said: 

But Ms Cundy concluded the hospital’s missed opportunity to establish Ms Anderson’s psychological history “did not more than minimally contribute to her death”. 

Ms Anderson's official cause of death was suicide, the coroner found. 

The coroner added she was "not able" to say whether Ellen would have stayed for the assessment, or still absconded, had she been referred. 

Ms Cundy said the hospital trust has since taken “appropriate steps” to improve the mental health risk assessment form protocol.

It has been “reinforced” that staff must complete the form fully, she said, adding staff must also “set in motion” the patients’ next steps.

The court heard the trust has also provided staff with ongoing training on how to establish a patients’ capacity.

Ms Cundy said there has been a “good level of compliance” since the trust revised its processes.

The coroner also addressed the “regular meetings” between the trust and the police, which aim to decide how responsibility is assumed in emergencies.

However, Ms Cundy added:

'Systemic incompetence'

Mark Anderson, Ms Anderson's father, today told the Stray Ferret something must be done to stop "this systemic incompetence" from happening again.

He said:

Hospital 'committed to learning from incidents'

Dr Jacqueline Andrews, executive medical director at Harrogate and District NHS Foundation Trust, said:

If you have been affected by this story or feel you need professional help, you can contact Samaritans on 116 123. A helpline is available 24/7.