Norfolk coroner’s call for lessons to be learned after death

A coroner has called for lessons to be learned after the death of a young woman 'in the prime of her life' who was discharged from hospital without her family being consulted first.

Kerry Ann Chapman, 27, suffered from a depressive illness and hanged herself at her home in Webster Close, Stoke Holy Cross, on August 4 last year.

Miss Chapman, who had a history of suffering from anxiety and had self-harmed in the past, was admitted to Carlton Court psychiatric unit in Carlton Colville on July 4 last year after taking an overdose.

She was detained under section two of the Mental Health Act and made further attempts to harm herself before being transferred to Hellesdon Hospital on July 13 after a third hanging attempt.

Miss Chapman, who was keen to go home, was discharged from hospital on July 26 last year after a review which found her condition had appeared to improve and that she was no longer expressing suicidal thoughts.

An inquest held at Norwich Magistrates' Court on Wednesday heard that Miss Chapman's family – including partner Peter Baker and mother Brenda – were not consulted over the decision to discharge her. Mr Baker, who had lived with her since 2007, said he found out from Miss Chapman that she was being discharged.

He said the family were surprised by her discharge: 'We felt she needed a period of stablilty.'

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Miss Chapman's mother Brenda said she only discovered Miss Chapman was being discharged after receiving a text from her daughter.

Norfolk coroner William Armstrong said: 'It's a matter of concern, grave concern, I have to say, that her family were not consulted before the decision was made to discharge her from hospital. In my judgement they should have been.'

The inquest heard that after Miss Chapman's death a root case analysis had been carried out by the Norfolk and Waveney Mental Health Trust and as a result procedures have now been put in place to ensure that families are fully consulted in the discharge process and that ongoing care plans and support are already in place.

Recording a narrative verdict Mr Armstrong said: 'Kerry Ann Chapman died as a result of her own actions at a time when she was suffering from a depressive illness. It's not possible to form a reliable judgement as to her intentions and state of mind at the time.'