6 December 2018

Before Senior Coroner Sarah Ormond-Walshe
South London Coroners Court
2nd Floor, Davis House, Robert Street, Croydon, CR0 1QQ

Opened Monday 3 December until 17 December

Catherine Horton, 49, was an inpatient at South London and Maudsley (SLAM) run Bethlem Royal Hospital in Beckenham, South London. She died of self-inflicted injuries at her home in Croydon on 24 July 2017, two weeks after absconding from the ward.

On 10 July 2017, hospital records indicated that staff had seen Catherine was safe and well on the ward, despite having left the premises a number of hours previously. Police were later alerted, and a missing persons’ investigation was opened. Catherine had previously absconded from the Bethlem Royal Hospital on 10 June 2017 and had been returned by the police.

On 17 July, the police investigation was closed without Catherine being located or having any contact with police. During the missing persons investigation, several members of the public who knew Catherine had reported seeing her near her home.

On 24 July, SLAM and the Metropolitan Police executed a section 135 warrant at Catherine's home to return her to hospital when it was discovered that she had died of self-inflicted injuries.

Catherine’s family hope the inquest process will address the following issues:

  • The adequacy of risk assessments, particularly regarding self-harm and suicide
  • The security measures implemented on the ward
  • The appropriateness of the prescribed medication and whether the failure to administer a further dose for a number of weeks may have contributed to Catherine's death
  • The adequacy of communication between the hospital, the police and the family
  • The quality of record keeping, particularly the records which indicated that Catherine was present on the ward when she had absconded
  • The delay in taking proper and timely steps to return Catherine to hospital

Lizzie Horton, Catherine’s sister said: “Catherine was much loved for the warm-hearted, gentle, funny, and free-spirited person that she was, and much admired for the way that she lived her life and battled with her illness and the mental health system. We intend to uncover the truth about what has gone wrong here.  In addition to sadness and loss, we have a very gruelling ordeal to go through, at what is obviously a very difficult time.” 

Natasha Thomson, Caseworker for the family at INQUEST said: “Catherine was profoundly unwell when she went missing from hospital, yet was only found two weeks later. We hope this inquest will address the family’s questions on the actions of police and mental health services, and explain why and how Catherine was not kept safe.”


For further information and to note your interest, please contact Lucy McKay on 020 7263 1111 or email  

INQUEST has been working with the family of Catherine Horton since September 2017. The family is represented by INQUEST Lawyers Group members Chanel Dolcy of Bhatt Murphy Solicitors and Tom Stoate of Garden Court Chambers.