High Court orders new inquest into death after ‘fresh’ evidence emerges
HULL WOMAN WAS TURNED AWAY FROM A MENTAL HEALTH FACILITY
A NEW inquest will take place into the tragic death of Hull woman Sally Mays after “fresh evidence” emerged.
Sally Mays, 22, who had mental health issues, died at home in Hull in 2014 after being refused admission to hospital.
Her parents Angela and Andy have fought for the past seven years for improvements to be made and lessons to be learnt from Sally’s death.
Sally took her own life in July 2014, after two nurses from Humber NHS Foundation Trust’s crisis team refused to admit her to hospital following a 14-minute assessment at Miranda House in Hull despite being a suicide risk.
An eight-day inquest in 2015 heard Sally, who had emotionally unstable personality disorder, died from an overdose and mechanical asphyxia after Yorkshire Ambulance Service took 99 minutes to reach her west Hull flat.
Now the High Court in London has ordered a new inquest into her death, the BBC reports.
During a hearing on Wednesday, Bridget Dolan QC, on behalf of Sally’s parents, said a conversation between one of Ms Mays’ care coordinators and a consultant psychiatrist on the day she died was “knowingly withheld” from the original inquest in October 2015.
She said the discussion revealed “a clear opportunity” to reverse the decision not to admit Sally.
Ms Dolan told the court hearing there was a “real possibility” the coroner’s conclusion would have been “differently framed” if the withheld material had been available and examined.
The inquest in Hull heard Sally asked to be admitted to hospital as her mental health deteriorated in the last few days of her life. Three nurses from her community team and her psychotherapist recommended a short stay in hospital in line with her care plan.
However, nurses Paddy Mckee and Gemma Pearson refused to admit her after carrying out what Professor Marks described as a “lamentable” assessment.
Instead, they called police when Sally started banging her head on a wall and tried to strangle herself in her distress.
However, police officers knew Sally needed to be in hospital to keep her safe and had a “stand-up fight” with the two nurses outside Miranda House to persuade them to change their minds. But they were forced to take Sally home when the nurses refused to reconsider.
The coroner at the time, Professor Paul Marks, said the decision not to admit Ms Mays constituted “neglect” which bore “a direct causal relationship to her death later that evening”.
He said that had she been admitted following an initial assessment she “would have survived and not died when she did”.
A further missed opportunity to save her life came from the 69-minute delay to an ambulance arriving at Sally’s flat after her 999 call was not categorised appropriately, the coroner said.
Following the inquest in 2015, coroner Prof Marks ruled the failure to admit Sally to hospital was neglect and said: “For the avoidance of doubt, had Sally been admitted, she would not have died that day.” However, Lady Justice Simler, sitting with Mrs Justice May and Judge Thomas Teague QC - the chief coroner for England and Wales - said it was “necessary and desirable in the interests of justice” to quash the inquest and order a fresh one.
In her ruling, the judge concluded that “fresh” and “relevant” evidence was now available and that a new inquest was “likely to lead to additional findings of fact being made”.
Speaking after the ruling, Ms Mays’ mother, Angela told the BBC: “All we’ve ever wanted is a full and fearless investigation into the facts of what happened to Sally in her final hours. “This has yet to be achieved.” A spokesperson for the Trust said it accepted the High Court decision and would assist the coroner with the new inquest but was unable to comment further due to the ongoing legal process.
Sally’s mum Angela previously expressed concerns no lessons had been learnt after the death of police officer Sharon Houfe.
She was horrified after learning of the failings, which led to the death of Sharon, bearing chilling similarities to her own daughter’s plight.
An inquest in December 2018, heard how PC Houfe, 43, had been seen three times in four days and had contact with Humber Teaching NHS Foundation Trust mental teams eight times in six days just before her death.
The inquest in Hull heard how there had been a catalogue of “missed opportunities” to refer PC Houfe to a psychiatrist or the crisis team before her death on April 29, 2016.
Mrs Mays said shortly after Sharon’s inquest: “It was an enormous sense of sadness and frustration to read what happened to Sharon Houfe.
“The trust just doesn’t seem to be much further forward and there are other cases similar to Sal and Sharon.
“It is all very well that people are being encouraged to speak about mental health, but there is little point if the help is not there.”
All we’ve ever wanted is a full and fearless investigation into the facts of what happened to Sally in her final hours
Angela Mays