16 November 2018

Before HM Assistant Coroner Lydia Brown
Leicester City and South Leicestershire Coroner’s Court, Town Hall, Town Hall Square, Leicester, LE1 9BG 

Opens 19 November, scheduled for 3 weeks 
Amanda Briley died on 28 December 2016, two days after she was found unconscious with a ligature on the Bradgate Unit, Leicester. She was an in-patient at the time of her death, detained under section 3 of the Mental Health Act. The inquest into her death opens on Monday 19 November.

Amanda had a history of serious mental ill health and prolific self-harm. At 13 years old she came under the care of Rugby CAMHS (Child and Adolescent Mental Health) and at 15 she was diagnosed with autism spectrum disorder (ASD). She was admitted as an inpatient on multiple occasions. 

Despite remaining at high risk throughout her admission, Amanda was granted overnight leave to her parents’ home on Christmas Eve 2016. Detailed arrangements were agreed to support her home leave, including the need to resume constant observations immediately upon her return to the hospital. Yet following her return to the ward the plan was not followed and she was left on hourly observations. Amanda was found in her hospital room during the early hours of 26 December following a ligature incident. She was transferred to hospital and pronounced dead on 28 December 2016.

At the time of her death Amanda was awaiting availability of a bed at St Mary’s Hospital in Warrington, a specialist in-patient unit for patients with autistic spectrum conditions.

Amanda’s family look to the inquest to address:

  • suitability of her prolonged placement on the Bradgate Unit, a non-specialist mental health unit
  • delays identifying and securing funding for a specialist placement and the impact this had on Amanda
  • adequacy of the care and treatment, including staff expertise and training
  • whether Amanda’s communication and other needs arising from her ASD were properly reflected in her care and clinical responses
  • management of her risk of self-harm and suicide, including in the management of her home leave and in the emergency response when she was found on the ward
  • information sharing and communication by all those involved with her care and with Amanda’s family
  • the lack of Safeguarding referrals made to either the Trust’s Safeguarding body or Leicestershire County Council


For further information, interview requests and to note your interest, please contact Lucy McKay and Sarah Uncles on 020 7263 1111 [email protected][email protected]
The family is represented by INQUEST Lawyers Group members Megan Phillips of Bhatt Murphy Solicitors and Maya Sikand of Garden Court Chambers.

The Interested Persons represented in the inquest proceedings are:

  • Family represented by Bhatt Murphy Solicitors
  • Leicestershire partnership Trust (LPT) represented by Browne Jacobson Solicitors
  • University Hospitals of Leicester (UHL) represented by Weightmans Solicitors
  • Leicester County Council (LCC) represented by Adult Social Care for Director of Law and Governance
  • Clinical Commissioning Group (CCG)
  • East Midlands Ambulance service (EMAS) represented by Weightmans solicitors.
  • Care Quality Commission (CQC)

A number of safeguarding investigations remain underway concerning Amanda’s death and the operation of the Bradgate Unit.