An inquest heard today found a 23-year-old Harrogate woman died of suicide.

Lisbeth Badrock lived on Leeds Road in Harrogate and was six years into a gender reassignment process when she died.

Today the inquest, held at Northallerton Coroners Court, heard her cause of death on November 16, 2021 was suicide.

Ms Badrock was transitioning from male to female, and had begun the process of taking hormonal medication.

The lead clinician in Ms Badrock’s care, Dr Laura Charlton, said she had spoken at length with Ms Badrock about her transition. Having been on medication for some time the next step would have been surgery.

Dr Charlton had discussed her surgical options and said Ms Badrock said she felt she would benefit from facial and neck surgery.

Mark Vickers, another member of Ms Badrock’s care team, said he had spoken to her in the months prior to her death about her mood levels.  She had reported her mood was dependent on the hormone medication she was taking but that is was generally good.

He had arranged for another appointment in January 2022.

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The inquest heard that  when speaking to officers following her death, her family and partner said she suffered with “bouts of depression”.

Ms Badrock’s father, Jonas Hartley, also gave a statement about his daughter who was working as a care worker at the time of her death. He said:

“She was generally happy, we thought she was becoming the Beth she wanted to be. I didn’t think she was at risk”.

Concluding the inquest, coroner Mr Jonathan Leach said:

“It is clear to me Beth was a 23-year-old in the midst of transitioning for which she was supported by doctors, colleagues and family. I am satisfied on this count due to the manor of her death that it was intentional and I conclude it as a suicide.”

An inquest into the death of a Harrogate woman has concluded that no single factor contributed to her taking her life.

Sarah Tatlow, 57, died at home on March 26 last year. At the time of her death she was undergoing treatment for an aggressive form of cervical cancer.

The two-day inquest in Northallerton, which ended today, heard Ms Tatlow’s husband, Julian Tatlow, question the actions of her doctors in the months leading to her death.

Mr Tatlow said his wife only became fully aware of her “poor prognosis” when a letter was sent days before her death.

The letter was written by Dr Isa Edhem, a consultant urological surgeon at Harrogate District Hospital, to Ms Tatlow’s GP practice. Mr Tatlow described the letter as “cold and insincere” and said it contained details not made clear to them during their consultation with Dr Edhem.

Harrogate District Hospital.

Mr Tatlow questioned members of his wife’s care team during the inquest, asking if they had made it clear to her how aggressive her cancer was. The doctors said they were sure Ms Tatlow knew her cancer was aggressive.

The coroner, Oliver Longstaff, said he took Mr Tatlow’s arguments into consideration but that there was no evidence the letter had a direct link to Ms Tatlow’s death.

Mr Longstaff concluded:

“Since it’s not known when that clinical letter arrived and indeed whether she had seen it, it is inappropriate for me to consider that a direct causal link can be found.

“Even if the letter arrived on March 26 and even if she had taken in the content, is there evidence this letter provoked her suicide over other factors?

“She was facing drastic surgery. I find it unrealistic to single out one factor only and say one was a trigger to this tragedy.”

He concluded the death was due to suicide and there was a clear link to her cancer.

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Hospital action plan

Mr Longstaff then read out an action plan written by Dr David Earl, on behalf of Harrogate and District NHS Foundation Trust, setting out a number of recommendations the hospital had put into place following Ms Tatlow’s death.

These included a protocol whereby, rather than sending letters to a patient’s GP, they are sent directly to the patient, explaining their prognosis and management plan. This is due to be rolled out across all departments by autumn this year.

It also suggested doctors would be more proactive with referrals to the cancer clinical psychology team if patients are struggling to cope.

Mr Longstaff said the trust’s action plan meant there was no need for him to write to the trust outlining his own recommendations.

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

“We would like to offer our deepest sympathies to the family and friends of Sarah Tatlow, and our thoughts are with them at this difficult time.”

A Harrogate man has told an inquest a “cold and insincere” letter from Harrogate District Hospital led to his wife to take her own life days later.

Sarah Jane Louise Tatlow, 57, died on March 26 last year at the home she shared with her husband and two sons in Harrogate.

She had been undergoing treatment for an aggressive form of cervical cancer.

Julian Tatlow told today’s opening day of the inquest in Northallerton that his wife was not fully aware of her “poor prognosis” until she received a letter from one of her doctors at Harrogate District Hospital days before her death.

The letter was sent following an in-person consultation with Ms Tatlow and her husband on March 17.

Ms Tatlow, who was a director of management training and development consultancy Kronos Learning, did not share the letter with her husband, who found it in the days after her death.

He described the letter as “cold and insincere” and said it contained details not made clear to them during the consultation.

He said the use of words such as “slurry” to describe the kind of faecal matter that would have ended up in his wife’s stoma bag, and the shock of her “poor prognosis” would have made his wife question “what is the point?”.

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Mr Tatlow told the inquest in Northallerton:

“I believe if she didn’t receive a copy of this letter, I may still have a wife and my sons a mother.”

The consultant who sent it responded to say:

“The extent of her cancer was confirmed on 10th March after numerous scans. I believe Sarah had come to the conclusion [of the severity of her cancer] following numerous consultations with myself and colleagues.”

Cancer diagnosis

The inquest heard that Ms Tatlow suffered frequent urinary tract infections in late 2020. A routine cervical screening in January 2021 then diagnosed cancer.

Dr Allison Amin, a consultant gynaecologist at Harrogate District Hospital, said she knew instantly it was an aggressive form of cancer that had spread to her pelvic area.

But Mr Tatlow said in an opening statement, which was read out at the inquest, that neither he nor his wife was aware of her “poor prognosis”. He said all the consultations had suggested that operations could “give her a better quality of life”.

Mr Tatlow asked each doctor if they had made it clear to his wife how aggressive her cancer was. Each doctor said they were unable to confirm their exact words but were sure Ms Tatlow knew her cancer was aggressive.

Mr Tatlow said to one of the doctors “my recollection is entirely different”.

He also asked why none had referred his wife to her GP for depression during a time in which, he said, she was clearly struggling.

At the time of her death, Mrs Tatlow was waiting for two surgeries that were due to take place early in April.

The inquest, led by coroner Oliver Longstaff, is due to conclude tomorrow.