1 December 2020

Before Dr Julian Morris, Assistant Coroner
London Inner South Coroner's Court

Held 23 to 30 November 2020

The inquest into the death of Claire Lilley concluded on 30 November 2020 with the jury finding there was a lack of consistent communication with her family and insufficient management of risk. Claire died while was she on leave from the Avery Ward at Oxleas House in Woolwich, run by Oxleas NHS Foundation Trust hospital.

Despite a psychologist’s assessment that Claire was at high risk of suicide, she was allowed to go on authorised leave overnight. After being briefly left alone, Claire was found by her mother, having ligatured at her home in Eltham on 12 February 2019.  She died in hospital a few days later 16 February 2019.

Claire Lilley, 38, was an assistant librarian from Eltham. Her family describe her as a very gentle, sensitive, proud and lovely person, who was extremely intelligent with a tremendous sense of humour. She had a talent for art, and had a Ceramics degree from Camberwell College of Arts. Claire loved going to exhibitions, reading, and being outside, especially walking her dog Kizzy.

Claire experienced depression with psychosis, and had previously been hospitalised during a depressive episode in 2010. In October 2018, Claire attempted suicide by overdose, triggered by a delusional belief that her neighbour was filming her. She was subsequently detained under the Mental Health Act in an Oxleas NHS Foundation Trust hospital, initially under section 2 (for assessment) in October then under section 3 (for treatment) from 2 November.

Claire was detained there until her death, but during this time leave from the hospital was authorised as part of her care plan. This included overnight leave at the end of December, and unescorted leave from the end of January, and the final overnight leave on 12 February 2019. The inquest jury heard that Claire's delusional belief and risk of suicide were present throughout her time under section. Despite this, from 30 January to 12 February 2019, the Trust did not actively seek feedback from Claire's mother as to how the leave at home was going.

Claire's mother gave evidence at the inquest on the weeks leading up to Claire's death, including her concerns about Claire's worsening anxiety and mental state while on leave. While Claire's mother had carefully documented each instance of leave, much of this information was not known to Oxleas NHS Foundation Trust as they had not sought feedback on the majority of Claire's leave periods during in 2019.

It was accepted by Claire's responsible clinician that this was a missed opportunity in relation to obtaining information relevant to risk. The only occasion where feedback was given in the two weeks leading up to Claire's death was when her mother brought Claire back from leave on 6 February 2019, as she was concerned about Claire's presentation and distress. However, no feedback was subsequently sought for the further periods of leave following this.

The jury further heard that there was no formulation of risk in the risk assessment, but instead a chronology of events. These did not include key disclosures which Claire made to the clinical psychologist, including her ambivalence towards life and her repeated disclosures that she had wished she’d died after the previous suicide attempt in October 2018.

The psychologist's assessment that Claire should not be left alone for prolonged periods of time, as she was at high risk of suicide, was not included in the risk assessment or communicated to Claire's mother. This is despite the fact that Claire went on overnight leave the day after this assessment was made. The risk assessment did not set out any triggers, or a risk management plan for when Claire was on leave.

The medical cause of death was found to be hypoxic brain injury by hanging. In a narrative conclusion the jury found that, while the main contributing factor leading to her death was mental illness, the following factors were relevant:

  • Communication between the family and the Oxleas Trust, and within the ward staff, was inadequate
  • There was a lack of consistent communication between the Trust and the family regarding feedback on home leave and risk management while on home leave
  • On the ward, relevant information was diffuse and there was no central formulation of the most pertinent information relevant to risk. This became especially relevant when several members of ward staff were on leave and there was insufficient management cover to review risk and make decisions in this particular case.

The Coroner confirmed that he would produce a Prevention of Future Death report in relation to the lack of a central document which formulates the risk, reflecting both the jury and family's concerns.

Brigitte Fortin, mother of Claire said: “I hope the death of my gorgeous Claire, who knew she was unwell but did not understand or comprehend the nature of her illness, will not be in vain.  I hope that her legacy will truly effect changes for other people, who sadly might find themselves in the same unfortunate situation.

If there had been proper assessments, accurate reporting of events and meaningful engagement and discussions with her family, it would have helped her recovery and reduced the risks associated with her mental illness.  Open communication involving her family and friends when on leave would have protected her life.

Our thanks go to our legal team and the INQUEST team for their infallible support and guidance through a very difficult period of our lives."

Chris Callender of Simpson Millar solicitors said: “It has been a difficult and distressing experience for the family to revisit the tragic circumstances which led to Claire's death. To hear from her responsible clinician that there was a missed opportunity through poor communications with the family confirms their concerns that the clinical team were unable to adequately assess the risk to herself while away from the hospital.   They hope that lessons will be learned and that the Trust will ensure that staff communicate with families and support networks involved in patients' care to ensure that risk assessments and care plans accurately reflect patient needs."

Jodie Anderson, INQUEST Caseworker supporting the family, said: “While leave can be an essential part of mental health treatment and care, it is essential that communication and risk is well managed. Too often this does not happen. The failures in this case left Claire’s family without vital information and support, and left Claire without the professional healthcare she needed. The Trust must now act on the coroner’s report to prevent future deaths, and this issue must be considered nationally.”



For further information please contact INQUEST Communications Team 020 7263 1111 or email [email protected]. A photo of Claire is available here.

The family is represented by INQUEST Lawyers Group members Chris Callender and Amy O'Shea of Simpson Millar Solicitors and Kirsten Heaven of Garden Court Chambers. They are working with INQUEST caseworker Jodie Anderson and previously with Theo Richardson-Gool. Other interested persons represented were Oxleas NHS Foundation Trust.

While initially ruling Article 2 of the European Convention of Human Rights was not engaged in this inquest on Friday 27 November, following further submissions from counsel for the family that same day, the Coroner produced a written judgment confirming that there was an arguable breach of Article 2 by Oxleas NHS Foundation Trust, and it was therefore engaged. This allowed for a more in depth inquest.