23 May 2019

Before HM Assistant Coroner David Reid
Winchester Coroner’s Court
29 April to 23 May 2019

The jury at the inquest into the death of Sasha Forster, 20, have today found that she died by suicide on 31 March 2017. Sasha Forster was detained under the Mental Health Act (MHA) but on leave from Farnham Road Hospital, a mental health hospital run by Surrey and Borders Partnership NHS Foundation Trust (SaBP) at the time of her death on 31 March 2017. Sasha was autistic and had confirmed diagnoses of Obsessive Compulsive Disorder and Post Traumatic Stress Disorder.

Assistant Coroner David Reid considered there was sufficient evidence for a jury to conclude that the following failures occurred:

• a failure by Surrey and Borders NHS Foundation Trust (SaBP) to recall Sasha from leave on the day of her death;
• a failure by Royal Surrey County Hospital staff to report Sasha to police as a missing person;
• a failure in SaBP’s crisis care planning for Sasha.

However, the coroner ruled that the jury could not safely conclude these factors were probably or possibly causative of Sasha’s death. The coroner said he was concerned to hear evidence that SaBP appeared unable to fulfil its legal responsibility to return to hospital patients subject to the MHA when their Section 17 leave had been revoked. He said this would be the subject of one of three reports he has decided to write with a view to preventing future deaths.

Sasha’s family said: “Sasha had so much to live for and she tried so desperately hard to get well.  We feel that this inquest has shown the flaws and inconsistencies in the system that let her down.

On the day of Sasha’s death there was no clear crisis plan in place for staff to follow, and the psychiatric team at Frimley Park Hospital refused to see Sasha. Surrey and Borders staff did not revoke Sasha’s Section 17 community leave, leaving her at high risk to herself in the community. Sasha was often dismissed by some staff as they labelled her as attention seeking, due to both incorrect suspicions of Emotionally Unstable Personality Disorder and rumours – which were completely unsubstantiated - of her having Munchausen’s (Factitious Disorder).

We hope that by shining a light on these issues, actions will be taken to prevent other young adults and their families having the same experience. We welcome the coroner’s decision to write three reports to prevent future deaths.” 

On the day of her death Sasha attended Frimley Park Hospital (FPH). She asked to see a nurse from SaBP’s psychiatric liaison team, based at FPH, because she was experiencing suicidal thoughts. Staff at psychiatric liaison refused to see Sasha stating that she should return to the ward or approach the Home Treatment Team. The inquest heard that shortly afterwards Sasha handed in a note to A&E staff at FPH in which she expressed clear suicidal intent. Sasha then returned home with her mother but ran away soon after. SaBP staff were informed about the note and told that Sasha had run away. Sasha’s responsible clinician did not recall Sasha from Section 17 leave.  

Sasha was reported to police as a missing person. Officers from Hampshire Constabulary encountered her in the early afternoon with a large quantity of the medication she would later use to overdose. Because Sasha was still on leave the officers did not have the power to detain and return Sasha to hospital.  Sasha’s mother was left to arrange Sasha’s return to Farnham Road Hospital.

Sasha’s mother suspected that she had already taken an overdose and took her to Royal Surrey County Hospital to seek treatment. Sasha ran away but the hospital staff did not report her to the police as a missing person. Surrey Police were informed that Sasha was missing about 20 minutes later. Despite extensive efforts the police were unable to locate Sasha for several hours, by which time she had already taken a lethal overdose. Sasha died shortly after 9pm that evening.

The inquest heard that Sasha had obtained two prescriptions of the type of medication that she used to overdose from two private GPs several months before her death. Sasha had not disclosed the full extent of her mental health history. The doctors prescribed Sasha the medication without asking for permission to access to her medical records or to consult her GP or psychiatric team.

Evidence was heard that some nursing staff based at Frimley Park Hospital believed that Sasha might have Factitious Disorder, a psychological disorder involving the feigning of symptoms. The evidence of clinicians was that even if some staff suspected that Sasha may have this disorder it did not affect Sasha’s treatment. However, Sasha’s family believe that this suspicion among staff, together with what the family consider to be a misdiagnosis of Emotionally Unstable Personality Disorder, and the fact that Sasha’s autism diagnosis was not confirmed until after her death, affected her treatment by both medical staff and the emergency services.

The coroner will be writing three reports, intended to prevent future deaths arising in cases like Sasha’s. These will be as follows:

• He will write to SaBP, their funders, and the Secretary of State for Health and Social Care, asking what action will be taken to ensure that SaBP is able to fulfil its legal responsibility to return detained patients who are absent without leave.
• He will write to all NHS Trusts, their funders, police forces in the areas of the hospitals involved in Sasha’s care and the Secretary of State for Health and Social Care regarding the need for collaboration between all services, trusts and emergency services to ensure better responses where a patient’s S17 leave revoked.
• He will write to the General Medical Council and Secretary of State for Health and Social Care about barriers to information sharing in cases such as Sasha’s between doctors in the private sector and those in the NHS.

Sasha’s family said: “Sasha was our gorgeous girl, a precious daughter, a loving sister, a loyal friend, and a spark of brightness in the lives of all those she knew.

Sasha’s health worsened when she was transferred from Child and Adolescent Mental Health Services to Adult services. At this point we feel there was an abrupt decline in the care Sasha received and the therapy she had been receiving as a teenager simply halted. Sadly, this resulted in a swift decline in her physical and mental wellbeing.

Over two years since her death, and after a four-week inquest with seven other interested persons consisting of three hospital trusts, two police forces and two private GPs, a thorough investigation into Sasha’s death has finally taken place.

Sasha found the early hours the most difficult to deal with, when most mental health services are closed. As a result, we are fundraising to open a crisis house in Sasha’s memory, which will be open all night and will welcome all those who struggle as Sasha did.

The family would like to thank their legal team Sophy Miles at Doughty Street Chambers, Catherine Shannon and Jed Pennington at Bhatt Murphy for their tireless work, incredible support and exceptional attention to detail. They would also like to thank George Julian for live tweeting the inquest, and the transparency it brings to the process.”

Deborah Coles, Director of INQUEST, said: “Deeply concerning evidence was heard during this inquest, which pointed towards gaps and missed opportunities in the way various agencies responded to Sasha’s mental health crises.  The failures in care planning, crisis support, and communication between the police and NHS services, are issues we are sadly all too familiar with.   

The mental health of young people is said to be a current political priority. Yet parents are still forced to become expert advocates, fighting for years just to get the care their children need and deserve. We welcome the coroner’s strong decision to make three Prevention of Future Death reports. These are lifesaving recommendations which must not be allowed to gather dust.”

Catherine Shannon, of Bhatt Murphy Solicitors and Sophy Miles of Doughty Street Chambers, who acted for the family said: “Sasha was detained under Section 3 of the Mental Health Act at the time of her death; she was at high risk and vulnerable. This inquest has raised important questions about the ability of mental health providers to plan crisis care for those on section 17 leave from hospitals and to recall and return them safely when this becomes necessary.”

ENDS

NOTES TO EDITORS
For further information please contact Lucy McKay or Sarah Uncles on 020 7263 1111 or [email protected]  [email protected]

INQUEST has been working with the family of Sasha Forster since May 2017.  The family are represented by INQUEST Lawyers Group members, Catherine Shannon from Bhatt Murphy Solicitors and Sophy Miles from Doughty Street Chambers.

As well as the family, other interested persons represented at the inquest were Surrey and Borders Partnership NHS Foundation Trust, Royal Surrey County Hospital NHS Foundation Trust, Frimley Health NHS Foundation Trust, Hampshire Constabulary, Surrey Police, Dr Deirdre Sills and Dr Stuti Hooda.