21 June 2021

Before HM Assistant Coroner Anna Loxton
Woking Coroners' Court

Heard 10 – 11 June 2021
Concluded 18 June 2021.

Sarah Hammond was 19 years old when she died a self-inflicted death on 22 June 2020. Despite her family’s concerns and request to pick her up, Sarah was discharged without their knowledge and put into a taxi home from Farnham Road Hospital after a mental health assessment. She was able to leave the taxi and died at Brookwood Railway Station.

An inquest has today concluded with the coroner finding no fault in the assessment or decision to discharge her, and making no criticism of Surrey and Borders Partnership NHS Foundation Trust, who run the hospital.

Sarah was studying Sport and Exercise Science at Loughborough University. Since the first wave of the Covid-19 pandemic in March 2020 she had been home in Woking, Surrey. Her family describe her as “beautiful on the inside and out”. She had a sweet, kind and hardworking spirit. She loved sports and participated in many, before discovering the one she loved the most which was cheerleading. But most of all Sarah loved her family, dogs and the simple things.

Sarah had a history of anxiety, depression and self-harm. She had previously been under the care of Child and Adolescent Mental Health Services (CAMHS), in 2016. In the months prior to her death, Sarah’s family had been concerned about her mental health, including whilst she was at university.  

When Sarah came home, ahead of the first lockdown, she seemed low in mood and had lost weight. Her mother was aware of an incident of self-harm. However, things seemed to improve and Sarah was able to spend some time staying with her boyfriend and focus on her exams and an upcoming part time job opportunity.

On 21 June 2020, Sarah was distraught after her boyfriend tried to end their relationship. Her parents were very concerned about her mental health. They advised that she stay home so they could look after her, and removed sharp objects from her room to try and protect her. However, she managed to find car keys and escape the house through a window. At around 1.30pm she drove off despite her mother trying to get in the car and stop her.

Her parents drove to Sarah’s boyfriend’s home, and tried to contact him and his mother. They were concerned she was going to harm herself. Sarah wasn’t responding to calls or messages. At 2.13pm they called 999 and reported their concerns to the police, who began to look for Sarah. They later found that Sarah was at her boyfriend’s grandmother’s house. Surrey Police attended and found Sarah was extremely distressed.

Surrey police tried to engage with her, but Sarah resisted assistance and did not engage. This led the police to use force to remove her from the property and eventually detained her under the Mental Health Act. An ambulance took Sarah to Farnham Road Hospital for assessment. She continued to be distressed throughout this time and tried to run away from the police and ambulance multiple times.

Sarah’s family contacted the hospital but were told they could not come to visit or bring Sarah anything. That evening Sarah spoke to her mother Sally on the phone and said that she was scared and lonely. Sarah told her mother that she wanted to die and wasn’t looking forward to any of the positive things in her life. Sally told Sarah that she was in the best place to be safe and get help, and encouraged her to be honest with the hospital staff and ask for what she needed.

The next morning, on 22 June, Sally again contacted the hospital. They repeated that the family could not come, and advised that Sarah would be assessed that afternoon. At 10.30am the mental health assessor called Sally. At the time the assessor was driving to the hospital and had the family on speakerphone. Sally gave details about recent events and Sarah’s mental health history, including self-harm and suicidal thoughts, and talking about trains.

Sally made very clear to the assessor that Sarah was in a mental crisis and that she no longer wished to live, and warned them to be careful that she would try to appear positive in order to get out. A few hours later, at 2.30pm, the assessor called back to say Sarah had appeared OK and that she would be discharged. Sally immediately said that this assessment was wrong, and didn’t reflect her behaviour the day before.

The assessor said they would send Sarah home in a taxi, but Sally said they wanted to come to collect her instead as they feared getting a taxi would be unsafe. Despite expressing her concerns, Sally felt she was not being taken notice of. The family were not informed when Sarah was discharged. Just after 4pm, after receiving no response to a message to Sarah or any further calls from the hospital, Sally phoned the hospital and was told she had left in a taxi at about 2.30pm.

Despite the hospital only being a 20-minute drive away, there was no sign of Sarah an hour and a half later. The hospital said they would check what happened and phone Sally back, but did not. Sally rang the hospital back 10 minutes later. She was informed that the taxi driver had said Sarah was going to her boyfriend’s in Windlesham but had been dropped off in Brookwood, which is miles away.

Sarah’s parents immediately drove to Brookwood Railway Station to look for her. They arrived and saw police tape, and were later informed that Sarah had died. At 3.10pm Sarah had texted her ex-boyfriend final words that indicated her intentions, but he had not seen the message until after her death.

After Sarah’s death the family were told that the taxi in fact left at 2.50pm and had pulled over when Sarah wanted to divert from the booked address, and phoned the hospital to check. The hospital said he should take her to the booked address. Sarah then let herself out of the car whilst the taxi had stopped at traffic lights in Brookwood. The driver informed the hospital of this at 3pm. This was recorded in the hospital notes, but the family were not told until after her death. The police had not been contacted after Sarah got out of the taxi at Brookwood.

After two days of evidence, the inquest concluded finding that Sarah took her life and did not find fault in the assessment of Sarah’s mental health and the decision to discharge her. The coroner recognised how important her family were to Sarah and “it would have been preferable” to offer to Sarah that her parents collect her to bring her home. The coroner also considered that it was “a regret” that Sarah’s parents were not told that she had got out of the taxi part way through the journey home. The coroner did not find the case met the requirements under Article 2.

Sally Hammond, Sarah’s mother on behalf of the family, said: “As a family we will forever cherish the memories we have with Sarah, and while a future without her seems so very bleak we feel absolutely honoured to have had her in our lives. We feel blessed to have known her and to have shared her company. Her sweet, kind and hardworking spirit is a rare and gorgeous mix and we know she has touched many lives apart from ours."

Janice Gardner of Russell Cooke Solicitors, who represents the family, said: “Our hearts are with the family of Sarah Hammond following the inquest into their daughter’s death. Over the two day inquest, Sarah’s mother Sally gave evidence that she told the Approved Mental Health Professional and staff at the hospital that Sarah would pull the wool over their eyes and hide her true mental state.

The family also made repeated requests to collect Sarah from hospital in the event that she was discharged, and it is incredibly unfortunate that these requests were ignored. Whilst we’re pleased to see that the Trust have amended their policy to put a greater emphasis on family members collecting people after they have been discharged, this change unfortunately came too late for Sarah.”

Nancy Kelehar, caseworker at INQUEST, said: “It is clear to INQUEST that Sarah and her family were seriously failed by Surrey and Borders Partnership NHS Foundation Trust, at a time when she was in crisis.

There was an unacceptable lack of active communication with Sarah’s family throughout her hospitalisation, including when she left the taxi. The insights of family members in the care of mental health patients are invaluable, but too often not given due consideration. More must be done, both in Surrey and nationally, to ensure families are active participants in care.”  

ENDS

NOTES TO EDITORS
For further information, interview requests and to note your interest, please contact Lucy McKay on 020 7263 1111 or [email protected]

Sarah’s family are represented by INQUEST Lawyers Group members Janice Gardner of Russell Cooke Solicitors and Sophie Walker at One Pump Court. The family are supported by INQUEST caseworker, Nancy Kelehar.

Other Interested persons represented are Surrey and Borders Partnership NHS Foundation Trust and Surrey County Council.

Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests