24 June 2024

Before Coroner Dr Robert Hunter
Chesterfield Coroner’s Court
Inquest opened October 2020
Concluded August 2021
Conclusions March 2023

Alison Henley was 53 years old when she died of an overdose at her home in Glossop, Derbyshire on 25 August 2016 after being able to stockpile medication prescribed by her GP. After a six and a half year wait for answers, her family are now speaking out about the impact of the delays and their continued concerns about Alison’s death.

Alison was a passionate fan of sport, particularly football and squash, and she had worked at England Squash for over 20 years, where she was a much loved member of staff. Alison was a very well known fan at her local football club, Glossop North End. Her family describe her as a loving and fun sister, auntie and sister-in-law, who often entertained her sister and beloved nephews with impressions and witty conversation. 

Alison had a long history of mental ill health and self-harm. She had a diagnosis of Emotionally Unstable Personality Disorder, anxiety and depression and had spent significant time as an inpatient at Tameside General Hospital. 

Alison also had poor physical health, which required a range of prescription medication following two operations in the three years prior to her death.

Her family who spent time with and spoke to Alison regularly, but lived a significant distance away in Norfolk, had been aware of Alison’s poor physical health but were not aware of the true extent of her mental ill health until after her death.

In the lead up to her death, Alison was engaged with mental health services at Pennine Care NHS Foundation Trust.  She had also been prescribed strong opiate pain medication along with a variety of other medication due to a range of physical health conditions and anti-depressants.

Alison had overdosed six times, including weeks before her death. She had also lost both parents and her close aunt which exacerbated her mental ill health, and led to her having to give up her job. 

At the time of her death, Alison was on a lengthy, 23 week, waiting list for Cognitive Analytic Therapy (‘CAT’). 

Two months before her death, Alison’s GP made the decision to reduce the frequency of Alison’s prescriptions in order to reduce the risk she could pose to herself. This change was not carried out. 

Instead, the way in which these prescriptions were managed by the GP Surgery allowed Alison to access additional quantities and stockpile medication. 

Giving evidence at the inquest, the GP said that, in retrospect, the monthly prescriptions Alison was receiving were “retrospectively probably in error.” Notes in Alison’s medical records state that the GP was concerned Alison would take her own life by accident. 

Asked whether it was safe to prescribe such a high quantity of a particular type of pain medication, the GP gave evidence at the inquest that she regretted prescribing this amount. Following Alison’s death, the GP surgery now carries out more thorough checks to monitor prescriptions. 

In addition, a witness from the pharmacy dispensing Alison’s medication admitted that there was a dispensing error and that they have changed their systems as a direct result of this.

In July 2016, the GP suggested to Alison’s psychiatrist that a multi-disciplinary team meeting would be useful, but the psychiatrist felt this would not be beneficial or in Alison’s best interests at that time.

On 3 August 2016, three weeks before her death, Alison had attempted to overdose. Whilst in hospital waiting to be assessed, she attempted to ligature and the item used was removed by staff. 

The next day, Alison was assessed by the Rapid Assessment Interface and Discharge (RAID) team. Alison told the assessor that she was unsure whether she could keep herself safe. The assessor decided to discharge her home “with knowledge that there was considerable risk” involved.

He clarified at the inquest, however, that he had assessed Alison as presenting a low risk to herself at that point as, amongst other reasons, she regretted the overdose and denied current suicidal thoughts. He also said that “there was significant risk of further overdosing’’ and that “any overdose is significant’’.

The assessor also told the inquest that he thought there was a “big risk for Alison of accidental suicide’’ and that the risks are particularly significant in relation to those with Emotionally Unstable Personality Disorder along with anxiety and depression. This concern was reiterated by Alison’s psychiatrist at the inquest.

On the night of 24-25 August 2016, Alison took a fatal overdose of prescription medication. 

Five years on from her death, the Coroner concluded that Alison died by “misadventure”. Despite the concerning evidence about Alison’s care, raised by the family, the coroner made no critical findings about the treatment Alison received. 

The family has serious questions about this and the way in which the inquest was conducted including the fact that they had to wait 19 months for the coroner’s final report. 

Kathryn Sault, Alison’s sister, said: “I believe that my vivacious, lively, intelligent, loving and humorous sister, Alison, was systemically failed. 

I do not agree whatsoever with the conclusions of this inquest. How could someone who had overdosed six times in 18 months and self-harmed frequently be deemed to have died from misadventure? I believe there were many facts pointing to her intent which have been ignored. 

However, the GP did state that she was worried that Alison would take her own life accidentally – so either way Alison was given the easy means to die deliberately or accidentally.

It is an insult for the coroner to say that there are no lessons to be learnt. When someone has taken their own life whilst under state care, there are always lessons to be learnt; otherwise it could happen again causing other patients and families to suffer.

The inquest process has been appalling. I had to wait for five years for the final hearing and was not given any apology or reasons for the extremely long delay until I complained and enlisted my MP’s help. 

I was also treated very unkindly by the coroner during the first hearing in October 2020, when an inquest is already a distressing experience. This severely affected my own mental health.

He questioned what I had done to help my sister even though I had already explained that I had done everything I could to help Alison with the limited information I had and living so far away.  She was under state care and they had a legal duty to look after her. 

I had a moral duty which I have undertaken the best I possibly could.  I should not have had to defend myself to the coroner at my sister’s inquest and made to feel responsible for her life. Inquests are not to apportion blame and yet I was made to feel blame by the coroner. 

He also compared my grief to the professionals’ distress at attending the inquest which is outrageous as they will not be affected every day by Alison’s death as I and my family are.

Those that had the chance to save Alison, many times, did not take it but I was not given the chance, and I have to live my life now without my sister.

I have never been the same since Alison died as there’s a melancholy that never goes away alongside my strong belief that Alison’s death could have been prevented by the people entrusted with her care; some of whom were crisis professionals.”

Clare Evans, solicitor for the family, said: “Alison’s sister has shown bravery and strength throughout this very lengthy and incredibly difficult inquest process. It remains a concern that after a serious overdose shortly before her death, Alison was discharged home with professionals acknowledging the ‘considerable’ risk involved, and yet there was no change in the level of monitoring or care provided.”

An INQUEST spokesperson, who worked with the family, said: “From the evidence, it is clear to us that Alison was not able to access the care and treatment she needed to address her needs or keep her safe. It is hugely disappointing that the coroner has not taken the opportunity to identify issues.

Instead of bereaved people being at the centre of the process, coroners or legal teams too often blame victims and their families rather than institutions responsible. 

Alison’s sister has been determined in her search for truth. Throughout a very difficult inquest process, she has shown immense strength. We stood with her on her ongoing search for truth and justice.”



For further information, please contact Leila Hagmann on [email protected] or 020 7263 1111.

The family were represented by INQUEST Lawyers Group members Clare Evans of Taylor Rose solicitors and Rachel Barrett of Cloisters Chambers. They were supported by INQUEST Senior Caseworker Nancy Kelehar.

Other Interested Persons at the inquest were Pennine Care NHS Foundation Trust, Alison’s GP, Derbyshire County Council, Tameside & Glossop NHS Trust and Cohen’s Chemist.

Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.

Since 2017 Alison’s sister, Kathryn Sault, and a friend also bereaved by suicide facilitate Empathy, a community group which they set up for people bereaved by suicide which provides peer support for people around Norfolk, where they are based.