15 February 2024

Before HM Area Coroner Dr Peter Harrowing
Avon Coroner’s Court, Ashton Court Mansion, Long Ashton, Bristol, BS41 9JN
Scheduled 19 – 23 February

Evangeline Wilson, 24, known to her friends and family as Evie, died a self-inflicted death on 10 July 2022 whilst on a period of 'short leave' from the Cassel Hospital, London. She was under the joint care of the hospital and Avon and Wiltshire Mental Health Partnership NHS Trust (AWP). An inquest will now examine the circumstances.

Born in Bristol, Evie was a joyful, mischievous and exuberant child. A talented artist, she had accepted a place to study fine art at a prestigious art school in London.

Evie had a complex history of mental health problems including bulimia, depression, severe self-harm, suicide attempts and post-traumatic stress disorder.

In 2022, Evie’s mental health team arranged a referral for residential treatment. On 22 June that year, she was admitted to the Cassel Hospital, London, as an informal inpatient.  

Evie then began to exhibit increasing distress. Several indicators in her care plan showed she was at high risk of self-harm. On 2 July, Evie had a seizure and developed a fever five days later. No medical investigation was undertaken. 

On 8 July, the decision was made that Evie should leave the Cassel Hospital on a period of ’short leave’ after staff had discovered that Evie had consumed alcohol to manage her distress. As this broke their behaviour contract, she was asked to return home for four days. 

An email was sent to her community mental health team (AWP) advising of her returning home. No-one checked if her social support was available that weekend.

The email was seen by her Consultant at AWP who put in place a safety plan for that weekend. The plan was as follows;

• Duty team to contact Evie by telephone on the Saturday and Sunday
• Crisis Team to be made aware that she had been sent home
• The Psychiatric Liaison Team to be made aware in case she presented at A&E
• A follow up on 11 July to discuss Evie’s care and arrange for her Care Coordinator to contact her.

Two days later, on 10 July, Evie was found dead in her flat. No one from the duty team contacted Evie over that weekend.

The inquest will seek to explore the following issues:

• Her mental health care and treatment by AWP between 16 September 2021 when the Cassel Hospital accepted Evie’s referral to the hospital, until her death.
• The pre-admission assessments and care she received at Cassel Hospital, including the response to the incident on 7 July which led to her being forced to return home on leave.
• The decision made for Evie to go on leave on 8 July 2022.
• The events between leaving Cassel Hospital and her death, including the action/inaction of AWP over that period.

ENDS

NOTES TO EDITORS

For further information, please contact Leila Hagmann on [email protected]. 

The family is represented by INQUEST Lawyers Group members Gemma Vine of Ison Harrison and Paul Clark of Garden Court Chambers. They are supported by INQUEST Senior Caseworker Selen Cavcav.

Other Interested persons represented are West London NHS Trust and Avon and Wiltshire Mental Health Partnership NHS Trust.

Other relevant cases

• Jess Durdy, 20, died on 16 October 2020 whilst at Link House crisis house in Bristol, having only moved in five days before. She had suicidal thoughts but was sent to a crisis house with untrained staff, rather than a formal mental health setting. Her family have spoken out about their frustration at the uncritical inquest into her self-inflicted death. Media release.
• Zoe Wilson, 22, died a self-inflicted death whilst a voluntary patient at a Bristol mental health hospital on 19 June 2019. An inquest found that multiple failings by AWP contributed to her death. Media release.
• Alexandra Greeenway, a 23 trans woman from Bristol, died a self-inflicted death on 11 May 2019. Just over a month before her death, she had been detained under section by police following a suicide attempt. The coroner did not draw conclusions on the quality of care Alexandra received from her GP or mental health professionals at AWP. Her family spoke about their frustration at the uncritical inquest. Media release.
• Luke Naish, 28, died in hospital on 2 October 2018, three days after he was found ligatured. Luke had both psychosis and substance misuse issues and was under the care of AWP community mental health services in Bristol. His parents remain concerned about the uncritical inquest and the care Luke received prior to his death. Media release.
• Becky Romero, 15, died in July 2017 shortly after being discharged from a mental health hospital in Dorset. The coroner found that her death was accidental and contributed to by neglect of AWP and Dorset HealthCare NHS. Media coverage.