Woman, 24, who died at Goodmayes station hours after being discharged not 'adequately assessed' by mental health team
PUBLISHED: 07:00 18 September 2019 | UPDATED: 09:39 18 September 2019
A 24-year-old woman who died after she was hit by a train at Goodmayes station was not "adequately assessed" by a mental health team before she was discharged from hospital just one hour earlier, an inquest heard.
Karis Braithwaite, from Dagenham, had tried to end her life by jumping onto the tracks at Dagenham Heathway the day before she died, on September 23, but the approaching train managed to come to stop and three members of the public helped pull her off the tracks.
Emergency services were called and she was taken to hospital.
The next day Karis underwent a mental health assessment, which took just 27 minutes, and the decision was taken not to admit her as an inpatient.
She was discharged from the hospital at 2.30pm and she was struck by a train at Goodmayes at 3.28pm on September 24.
Karis' family said they are "grateful" to the coroner for concluding that Karis should not have been discharged from hospital the day she died.
Karis, who had suffered from depression since the age of 13, had a long history of mental health issues, the inquest heard, and she was under the care of North East London Foundation Trust (NELFT) at the time of her death.
She had been living in supported accommodation in Heathway, Dagenham, which provided 24-hour care, with four other patients.
On September 23, Karis had an argument with some of the staff and other residents at her accommodation and had left shortly afterwards to go to Dagenham Heathway Underground station.
After she was helped off the tracks, Karis told the paramedic who attended that she had an "active plan of suicide" and she "would succeed", the inquest heard.
"Karis kept saying she wanted to end her life," senior coroner Nadia Persaud said at the inquest conclusion on Tuesday, September 17. "The paramedic who attended had met Karis on two previous occasions.
"The paramedic made clear that she had an active plan of suicide and told hospital staff that she should be taken very seriously."
But NELFT staff were not "receptive" to receiving a handover from the paramedics, outlining their concerns about Karis, Ms Persaud said.
A police officer who attended the incident at Dagenham Heathway also said trust staff were "obstructive" when trying to provide a handover.
Karis was admitted to hospital and a Section 136 assessment, part of the Mental Health Act which can be used to section a patient, was carried out by two psychiatrists the next day.
But the psychiatrists did not see key information from the paramedics on Karis' records and did not know all the details of the events that had ensued the day before, the inquest heard.
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Karis told psychiatrists she was no longer suicidal, but she was angry about the train incident the day before and said she wished it had worked. "Karis said she did not know why people were trying to control her life. She said her life belongs to her so why should people try and stop her from killing herself," Ms Persaud said.
The decision was taken to discharge Karis and a plan was put in place which meant Karis was supposed to go home in a taxi with a member of staff and the home care treatment team would be in touch.
Instead, she caught two buses to Goodmayes station.
Following her death, Karis' family made a formal complaint to NELFT.
An investigation following the complaint about her care found that the decision to discharge Karis was "not appropriate" and "flawed".
"She showed clear and unequivocal evidence of suicidal behaviour of the highest risk," the report said. "The decision to discharge Karis so soon after the incident was not based on reliable information."
While an independent expert witness said the decision to discharge or admit Karis to hospital would have been complex, he also concluded that "the very serious suicide attempt should have resulted in her being detained and not released".
The decision to discharge Karis would have been a matter of individual clinical decision making, the inquest heard.
In her findings, Ms Persaud recorded a verdict of suicide.
"I am satisfied, without any doubt at all, that Karis had intended to end her life at that point," she said.
But she added that the paramedic had been very concerned ` at Dagenham Heathway the day before Karis' death and the handover to trust staff about Karis' mental health condition had been inadequate.
Senior coroner Nadia Persaud said: "Karis Braithwaite took her own life in part because the risk of her doing so was not adequately assessed and appropriate precautions were not taken to prevent her from doing so.
"If Karis was admitted to hospital I am satisfied she would not have come by her death an hour later."
Ms Persaud filed a report to prevent future deaths in relation to the handover between emergency services and NELFT in these types of incidents.
NELFT has 56 days to respond to the report.
On behalf of Karis' family, Tim Deeming from Tees Law said: "We are grateful to the coroner for carefully considering all of the evidence and concluding that Karis should not have been allowed to leave the hospital.
"However we are now calling on the hospital to demonstrate that they will change both how they obtain and consider all vital information needed to support and assess vulnerable patients, given that we understand similar issues have tragically happened before; as well as improving their culture given the evidence of the police and paramedics of ongoing resistance by the hospital in accepting patients like Karis who need such help and support."