Coroner slams hospital trust after woman’s suicide

PUBLISHED: 12:00 02 January 2020

The coroner concluded that Karis Braithwaite, should not have been discharged from hospital by mental health teams. Picture: Tim Deeming

The coroner concluded that Karis Braithwaite, should not have been discharged from hospital by mental health teams. Picture: Tim Deeming


A senior coroner has criticised an NHS trust after staff missed a woman’s suicide threat before she took her own life.

Karis Braithwaite from Dagenham stepped into the path of an oncoming train at Dagenham Heathway station on September 23, 2018.

As the driver performed an emergency stop, bystanders pulled the 24-year old away. Karis, who had a history of suicide attempts, was taken to Goodmayes Hospital and sectioned.

Karis told a paramedic she wanted to take her life that day. The medic tried telling Goodmayes staff, besides putting her concerns in writing.

But at an inquest which concluded on September 17, 2019, the paramedic told senior coroner Nadia Persaud staff were not "receptive" to a verbal handover.

Some of her notes were added to the hospital's electronic records but the mental health risks were missed out.

A team spent 27 minutes assessing Karis the next day, but they did not see a record of the paramedic's verbal handover or the written notes.

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Karis was released from being sectioned and left Goodmayes, taking the bus to Goodmayes station where at 3.28pm, she stood in front of a non-stopping, fast train. She suffered fatal, multiple injuries.

In a prevention of future deaths report sent to NELFT, Ms Persaud raised concerns that the paramedic's "important risk information" was not available to the mental health team.

And Ms Persaud reminded NELFT of a separate report sent December 2016 which observed that "inadequate questions" were asked by Goodmayes staff about the mental state of another person who had died.

"[T]here is a concern that insufficient steps have been taken by the trust to improve the handover process", Ms Persaud wrote.

A NELFT NHS Trust spokesman said: "We have offered our sincere condolences to Karis's family and friends following her tragic death.

"We have also responded to Her Majesty's coroner in relation to the learning identified in the report, informing the coroner on how the trust is going to prevent recurrence of similar shortcomings within the service.

"The trust takes learning from deaths very seriously and continuously strives to improve its services.

"It is grateful to the coroner for the lessons identified at the inquest and is determined to ensure these lessons are learnt fully and effectively to improve its service."

For anyone having suicidal thoughts contact Samaritans on 116 123.

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