Mental health trust neglectful over woman's death

A mental health trust that discharged a patient despite a "real and immediate risk to her life" was neglectful in its conduct, a coroner has said.

Abbi Smith, 26, died the day after her release from the Linden Centre, an inpatient unit run by Essex Partnership University NHS Foundation Trust (EPUT).

A three-week inquest found Ms Smith, from Braintree, was not kept safe and staff failures to recognise that she was autistic had a "profound impact" on her care.

Paul Scott, chief executive of EPUT, said: "Abbigail did not receive the care she needed and deserved and for that I would like to apologise."

Delivering her conclusion at Essex Coroner's Court, area coroner Sonia Hayes said Ms Smith's death was "avoidable".

She was found dead at a park in Braintree on 15 February 2022, having taken her own life.

During the inquest, her mother, Lisa Wolff, said she was "a kaleidoscope of ever-changing colours and patterns" who loved singing and animals.

Ms Smith spent eight of the 10 years up to her death in and out of mental health units.

Her final discharge came days after she attempted suicide and even told staff of an intention to do so again upon being sent back to her supported living accomodation, the inquest heard.

Ms Smith also made a video in which she said: "Last night I was crying and crying. Couldn't stop. Not one member of staff came in to see if I was OK."

Ms Hayes said there was a "real and immediate risk" to her safety if discharged, but staff pushed ahead anyway that February.

"There was nothing to mitigate this risk," the coroner added.

This amounted to a "gross failure" and there were missed opportunities to prolong Ms Smith's life, the coroner stated.

Mrs Wolff wrote to her daughter's psychiatrist shortly before the discharge, asking him to consult a specialist autism unit about how to reduce her risk of self-harm in the community.

However, she did not receive a reply.

The inquest heard Ms Smith was diagnosed as being autistic and having learning difficulties at a young age.

Ms Hayes said her autism was never properly assessed and instead she was given mental health diagnoses that may not have been correct, rendering her care plan ineffective.

"Abbi's autism was left as a footnote in her care," Ms Hayes said.

Referring to Ms Smith's video before her death, the coroner added: "Abbi was so much more than her diagnosis... and sadly her distress was palpable in the video."

Speaking after the inquest, Mrs Wolff from Dorset, said of her daughter: "She was a young autistic woman who had her own hopes and dreams, such as swimming with dolphins or owning her own dog.

"These were not grand aspirations, but they were her aspirations and they were taken away from her by the very professionals that were supposed to support her."

Mr Scott said his apology was both personal and on behalf of the trust.

He added: "My condolences remain with [Ms Smith's] family and all who loved her at this difficult time."

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