28th September 2016

Blackburn Coroners Court, Ribble Valley Town Hall, Clitheroe.
Before HMC Michael Singleton

A Coroner has returned an ‘Open’ verdict into the death of D’Anna Ward, aged 20, who took her own life on 7th August and died in hospital four days later, whilst under the protection of a Community Treatment Order (CTO).

D'Anna began to develop mental health problems in her late teens and was detained under the Mental Health Act when she started to self-harm and put herself at risk. After a diagnosis of Emotionally Unstable Personality Disorder, efforts were made to find a specialist service for her in the north of England so that she could maintain close contact with her family but the only appropriate service could not accept her mainly due to not having any available bed for next 2-3 months. 

Despite her having self-harmed whilst in hospital (including by ligature) during the summer of 2014, a decision was made to discharge D'Anna to a supported living placement in the community: Prospects in Accrington, Lancashire. She was required to reside at that placement as a result of a community section of the Mental Health Act (a Community Treatment Order). The plan was for The Bradford District Care Foundation Trust to hand over D'Anna's care after 3 months, but the handover was significantly delayed and did not in fact take place until the 29 April 2015, 6 months later.

Deborah Coles, Director of INQUEST said:

“INQUEST shares D’Anna’s family’s call for greater investment in specialist services for young women with complex personality disorders. We have serious concerns around multi-agency co-ordination of care and the decision taken to place such a vulnerable young woman, with a recent history of self-harming, into the care of unregulated, privately run supported housing. “

Jim Gladman, the family’s solicitor said:

It has been very difficult indeed for D'Anna's family to hear, over the past 6 days, just how many opportunities to help D'Anna were missed. They were very disappointed and upset at some aspects of the care provided by Prospects, at the time, but did not feel listened to. They are equally very disappointed that the Coroner felt that it could not have been reasonably anticipated that D’Anna would take her own life given her history of previously failed suicide attempts”.

INQUEST has been working with the family of D’Anna Ward since November 2015.  The family is represented by INQUEST Lawyers Group members Michael Kennedy and Jim Gladman of Switalskis Solicitors.


Notes to editors:

Helen Millard’s inquest which concluded this week highlighted similar issues. See here

For further information, please contact Selen Cavcav on tel. 0207 263 1111.

INQUEST provides specialist advice on deaths in custody or detention or involving state failures in England and Wales. This includes a death in prison, in police custody or following police contact, in immigration detention or psychiatric care. INQUEST's policy and parliamentary work is informed by its casework and we work to ensure that the collective experiences of bereaved people underpin that work. Its overall aim is to secure an investigative process that treats bereaved families with dignity and respect; ensures accountability and disseminates the lessons learned from the investigation process in order to prevent further deaths.

Please refer to INQUEST the organisation in all capital letters in order to distinguish it from the legal hearing.