'Missed opportunity' to stop young woman leaving hospital hours before suicide, inquest

  • ITV Meridian's Kit Bradshaw has spoken to Rachel's parents following the inquest.

There was a missed opportunity to prevent a talented young musician from leaving hospital just hours before she took her own life, a coroner has concluded.

Rachel Garrett died in Brighton on 29 July 2020, after five suicide attempts in a four-week period. Hours earlier, she had walked out of the Royal Sussex County Hospital after ‘miscommunication’ between a doctor and nursing staff over using powers of detention.

Recording a narrative verdict, Senior Coroner Penelope Schofield said: “There was a missed opportunity to prevent her from leaving the Royal Sussex County Hospital for the second time on 29 July. 

“It seems to me individuals [in mental health crisis] can easily leave this setting when it’s not in their best interest to do so.”

The inquest heard that Rachel had been diagnosed with emotionally unstable personality disorder, following a mental breakdown the previous year while studying to become a teacher at Bath Spa University.

During the two-week inquest, psychiatrists and police officers defended their actions in the months leading up to her death. 

Sussex Partnership NHS Foundation Trust staff had discharged Rachel from Meadowfield Hospital in Worthing after a 72 hour stay in April 2020, despite Rachel saying in a letter to them that she feared she’d “relapse” if she didn’t remain in a secure unit. 

Another doctor from the same trust released Rachel from Mill View Hospital in Hove in July, just weeks before her death, despite her family’s desire for her to be admitted to a psychiatric ward.

The inquest heard that there were five attempts by Rachel to end her life over four weeks before her death in July 2020. Credit: Family handout

In written evidence, Rachel’s parents said doctors relied too heavily on a working diagnosis and ignored “her complex medical history, particularly of cerebral palsy”.

During one incident, on 17 July 2020, Rachel was restrained in Brighton by members of the public and police to try to prevent her from harming herself. During that struggle she was arrested for assaulting a mental health nurse and police officer and taken to custody. 

The inquest heard Rachel’s cause of death will be recorded as multiple injuries, with fall from height and a complex mental health disorder listed as contributory causes. 

Staff failed to prevent Rachel Garrett leaving the Royal Sussex County Hospital on the day she took her own life, an inquest heard.

Sussex Partnership NHS Foundation Trust and University Hospitals Sussex said: "Our thoughts and condolences are with Rachel Garrett's family and friends.

"We acknowledge the challenges in supporting Rachel's highly complex, fluctuating mental health difficulties and the impact this had on her family.

"As a priority, we are working with our health care partners to continue to improve the ways we collaboratively support vulnerable mental health patients in crisis and keep them safe."

Rachel was 22 at the time of her death and was a talented musician. She had played drums in local punk rock band ‘Grasshopper’ since the age of 14.

Tributes have described her as having an “infectious sense of humour and positive outlook”.

Rachel Garrett played drums in local punk rock band Grasshopper. Credit: Simpson Millar Solicitors handout

Detective Superintendent Rachel Carr of Sussex Police said: “Our sincere condolences go to the family and friends of Rachel Garrett.

“Rachel’s family have worked tirelessly and with dignity to ensure the challenges faced by Rachel were properly scrutinised at her inquest. We fully supported the coronial process in every way we could.

"Keeping people safe is our priority and we work closely with partners to provide vulnerable people with the support they need. Safeguarding those with complex mental health needs is challenging and, with Rachel, officers did all they could within the law to protect her."

The Independent Office for Police Conduct confirmed it had investigated the Sussex force, following a mandatory referral in relation to the contact officers had with Rachel prior to her death.

Rachel’s family said she had an “infectious sense of humour and positive outlook”.

An IOPC spokesperson said: “We found no indication that any person serving with the police had committed a criminal offence or behaved in a manner justifying the bringing of disciplinary proceedings.

“Police officers have a power to detain someone under section 136 of the Mental Health Act in limited circumstances. Rachel was not detained using this power, however, officers acted in line with policy by consulting with a mental health nurse when making their decisions.

“We did find one officer would benefit from reflecting and learning from their failure to effectively communicate with a mental health nurse in relation to the use of police powers under section 136 of the Mental Health Act.”

Senior Coroner Penelope Schofield said she was minded to issue a prevention of future deaths report to NHS Sussex and NHS England in relation to Rachel's case in the coming months.

If you need support you can call the Samaritans for free on 116 123.

If you are experiencing a mental health problem you can call SANEline on 0300 304 7000

You can also contact the National Suicide Prevention Helpline UK on 0800 689 5652