29 January 2019

Before HM Deputy Coroner Briony Ballard
Southwark Coroner’s Court
21 – 29 January 2019

On 29 June 2017 Agnes McDonald walked out of the Ladywell mental health unit, run by the South London and Maudsley NHS Foundation Trust (SLAM), and died when she was struck by a train at Clapham South train Station.  She had been admitted to the Unit as a non-sectioned patient just three weeks before her death. An inquest jury has today concluded, finding that Agnes took her life while on leave from the Ladywell Unit. 

Agnes, 41, had a long history of mental ill health, starting when she was a child. She made two suicide attempts as a young adult and then following a period of relative stability, her health deteriorated again in her late 30s. She had been hospitalised on multiple occasions.

Less than a month before her death during a serious deterioration in her mental health, a decision was made to cease providing Agnes with medication for six weeks. A few days later she was admitted to the Ladywell Unit, Lewisham Hospital, following a fire in her flat.

In a final call the night before her death, her family described Agnes sounding drowsy and unhappy on the ward.  She was allowed to leave the ward on 29 June 2017 and died when she was struck by a train at Clapham South Train Station just a few hours later.

The inquest followed long, unexplained delays in SLAM’s completion of its investigation into the circumstances of Agnes’ death. Following this conclusion, the Coroner will be writing to the Trust to seek reassurance that changes promised at this inquest are implemented.

Agnes’ brother, James McDonald said: “My sister had a beautiful soul and up to the very end of her life she was still trying to help others. We know how disregarded Agnes felt in with the mental health treatment she received and how upset this made her.  This inquest has finally given us the opportunity to voice our concerns regarding her care.

We had no choice but to rely on medical professionals to keep our sister safe.  We still do not understand why she wasn’t given the help and support she needed.  We feel let down that she didn’t get the therapy she had been asking for.  We feel that her medication wasn’t properly monitored.  Finally, we feel that it appears that she wasn’t listened to and taken seriously enough.

We are pleased that the Coroner has asked the Trust to explain what steps they are taking to improve their services to ensure that lessons are learnt, and future suffering prevented.”

Victoria McNally, Caseworker at INQUEST, said: “Despite this disappointing conclusion, we hope that SLAM will respond seriously to evidence of poor care and treatment exposed through this inquest, which was clearly such a source of distress to Agnes in the final period before her death.”

Chris Callender of Simpson Millar solicitors who represented the family, said: “Agnes’ family have been waiting for many months to establish whether more could, and should, have been done to protect her. They have long had concerns with regards to a number of aspects of her care; including a period during which she was taken off her medication with no comprehensive plan in place to support her should she find herself in crisis.

The family are concerned about the lack of care Agnes received from the Community Mental Health Team to ensure she had access to talking therapies and robust medication management.  This has had devastating and heart-breaking consequences for Agnes’ family, who are calling for the Trust to put immediate safeguarding measures into practice to prevent future families from suffering similar tragedies.

Her family argue that the decision to cease her medication contributed to her feelings of low mood and suicide contemplation.  The family were concerned to hear evidence about the lengthy delays to provide Agnes with talking therapies, the poor medication management and that Agnes seemed to fall between services.“


NOTES TO EDITORS For further information please contact Lucy McKay on 020 7263 1111 or email. 

INQUEST has been working with the family of Agnes McDonald since November 2017. The family are represented by INQUEST Lawyers Group member Chris Callender of Simpson Millar Solicitors and barrister Rachel Barrett.

South London and Maudsley NHS Foundation Trust:

South London and Maudsley NHS Trust provide mental health services for people in South London, including the Ladywell Unit in Lewisham Hospital, Bethlem Royal Hospital in Croydon, and the Maudsley Hospital in Denmark Hill.

Numerous inquests on deaths in their mental health facilities in recent years have highlighted failures and, in some cases, neglect.

  • Catherine Horton, 48, was an inpatient in South London and Maudsley (SLAM) run Bethlem Royal Hospital when died on 24 July 2017. An inquest in December 2018 concluded that she died from suicide, contributed to by neglect on the part of the medical and nursing team responsible for her care.
  • Katy Roberts, 16, was in the care of SLAM Children and Adolescent Mental Health services in when she died a self-inflicted death in October 2017. An inquest highlighted failures in care planning and communication in April 2018.
  • Rosie Flett, 21, was a detained inpatient also on Gresham 1 Ward Bethlem Royal Hospital when she died on 11 February 2017. The inquest found searches and observations were not effective in locating blades used for self-harm, despite five previous incidents of cutting. The Coroner Selena Lynch wrote a Prevention of Future Deaths report in May 2018.
  • A.H., 27, was a detained inpatient at Bethlem Royal Hospital when she was on unescorted leave and died on 18 August 2016. The inquest in May 2017 found failings in the hospital’s recording and updating of risk assessment, and that adequate steps were not taken to ensure she had taken necessary medication.
  • Christopher Brennan, 15, was a voluntary patient at Royal Bethlem Hospital adolescent unit. On 21stSeptember 2016 an inquest found his death was also contributed to by neglect. The inquest also found cumulative and continuing failures in risk assessment. Coroner Selena Lynch wrote a Prevention of Future Deaths report in December 2016.
  • Olaseni ‘Seni’ Lewis, 23, was a voluntary patient at Royal Bethlem Hospital and died on 31 August 2010. An inquest found multiple failures at multiple levels within the hospital meant that the staff had to call upon the assistance of the police when he became unwell. Seni was excessively restrained by 11 police officers as medical staff stood by.