12 June 2023

Before HM Acting Area Coroner Catherine Wood
Maidstone Coroner’s Court
5 – 9 June 2023

An inquest has concluded finding failures in risk assessment, documentation and support, along with insufficient observations due to lack of staff in a Kent mental health ward, contributed to the self-inflicted death of a woman in her 50s.

June Angela Challis, known to her family and friends as ‘Angie’ died aged 55 on 22 August 2022. Angie was from Deal in Kent. She had two daughters Carley and Jade who she said were the positive things in her life.

Angie had previously been admitted to hospital when experiencing severe post-natal depression. She again began to experience mental health issues following menopause in 2017 and had deteriorated further since 2020.

Angie had a diagnosis of ‘Treatment Resistant Depression’ and as a result she often expressed feelings of hopelessness. She was treated by Community Mental Health Teams with the involvement of the Crisis Team.

Foxglove Ward, St Martin’s Hospital

On 21 April 2022, following overdoses and self-harm attempts in the community, Angie was admitted as an informal patient to the Foxglove Ward, an acute psychiatric ward at St Martin’s Hospital under the care of Kent & Medway NHS Trust. During her admission Angie self-harmed, including swallowing objects.

On 23 June 2022, due to incidents of self-harm, it became necessary to detain Angie for treatment (under Section 3 of the Mental Health Act).

Chartwell Ward, Priority House

On 5 July 2022, Angie was transferred to the Chartwell Ward at Priority House, under the care of Kent & Medway NHS Trust. This was to enable Angie to undergo Electroconvulsive Therapy (“ECT”) sessions.

During her time on the Chartwell Ward, Angie continued to self-harm including swallowing objects, in the period prior to her death, particularly when she was feeling anxious. Upon completion of ECT sessions there were discussions about her discharge, but there was a lack of a structured care plan in place for her. Angie was anxious about returning to the community.

On 11 August 2022, after a discussion about her discharge, Angie had swallowed items from the ward which had blocked her airway and as a result she turned blue. She received back slaps and abdominal thrusts from staff and was able to dislodge the item. Angie was not placed on intermittent observations until the next day. 

There was no risk assessment recorded or review carried out relating to the change in her observations. On 12 August 2022 despite the fact she was on intermittent observations (4 per hour) there was no evidence that she was observed for a period of almost 10 hours. On 15 August 2022, there was a meeting about her discharge. 

Angie’s daughters expressed their concern about their mum returning home without receiving the support she required to keep her safe. The escalating risks, anxiety over discharge and self-harm incidents were not commented upon.

Later that day Angie placed an item in her mouth but removed this following a discussion with staff. Despite this, her level of observation was not upgraded from intermittent to 1:1. A further incident on 18 August 2022 ultimately led to her death. 

At around 6pm in the evening, Angie was observed to be pacing the communal corridor which was a known indication that Angie was anxious and likely to experience a panic attack. Shortly afterwards Angie would be found to have swallowed items which caused her to choke.

Despite staff responding with back slaps and abdominal thrusts, the item had blocked her airway and she became unresponsive. An ambulance was called and the paramedic was able to remove the items from Angie’s throat. Although she began to breathe again, Angie later died on 22 June 2022 following the removal of life support.


An inquest took place into Angie’s death between 5-9 June 2023. After hearing evidence from staff involved in Angie’s care and treatment in the community, as well as treating clinicians on both wards, the jury concluded that:

  • There was insufficient information provided to staff to ensure adequate care.
  • She was not sufficiently observed due to lack of staff.
  • There was a failure of acceptable support in relation to discharge anxiety.
  • Defective assessment and documentation of risk-assessment relating to Angie’s risk of self-harm and triggers for exacerbation of her mental health.

Kent and Medway NHS Trust have admitted to failures with regard to observations, risk assessment and recognise that there was insufficient staffing levels available at the time of Angie’s death.

Carley McNamara, Angie’s daughter said: “Both myself and my sister Jade miss our Mum so much and her beautiful smile. During our childhood she always provided us with the care and support we needed. Our Mum always made us laugh and was always singing.  She loved those around her endlessly. She had such a strong relationship with her grandson.

When my Mum was admitted to hospital it was such a difficult time for all of us. However, we were sure that she would be get the care that she needed. Since my Mum was told that she had ‘Treatment Resistant Depression’ she felt that she would never get better. I know that Mum was worried about being discharged into the community again.

We were distressed to discover that despite numerous swallowing incidents that my mum had not been risk assessed or placed upon the appropriate level of observations. We really do hope that changes are made so that no other family has to experience the devastating pain and loss suffered by our family.”

Leanne Devine of Scott Moncrieff Solicitors said: “Angie’s death highlights the tragic consequences of significant lack of staffing, resources and funding in our NHS. However, whilst a lack of staffing unpinned one of the failures identified, it is important to recognise that the failures in Angie’s care were also often due to a lack of basic medical care.

The evidence heard during the Inquest demonstrated that her care was uncoordinated, with a lack of support provided to Angie and her family during a complex time and there were concerns that the pattern would repeat upon Angie’s discharge. 

Further changes are needed with KMPT to ensure full and proper record keeping, communication with staff, risk assessments and the observations to keep patients safe. 

We await to hear from the coroner with regard any Prevention of Future Death reports she considers appropriate.”

Lucy McKay, spokesperson for INQUEST, said: “Angie needed care and support, and Kent & Medway NHS Trust should have been equipped and able to keep her safe. The evidence has shown that they were not. Women are being consistently failed by ineffective inpatient care.

In the short term we hope the Trust will act urgently on the findings of this inquest, to keep other patients safe. In the long term, we must see systemic change across mental health services to enable better access to effective care.” 


For further information, interview requests and to note your interest, please contact Lucy McKay on 020 7263 1111 or [email protected]

The family is represented by INQUEST Lawyers Group members Leanne Devine, Human Rights Lawyer and Consultant Solicitor at Scott Moncrieff Solicitors and Counsel Angelina Nicolaou of One Pump Court Chambers.

The family are supported by INQUEST caseworker Caroline Finney.

Other Interested persons represented are Kent and Medway NHS Mental Health & Social Care Partnership NHS Trust

Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.

INQUEST is the only charity providing expertise on state related deaths and their investigation to bereaved people, lawyers, advice and support agencies, the media and parliamentarians. Our specialist casework includes death in police and prison custody, immigration detention, mental health settings and deaths involving multi-agency failings or where wider issues of state and corporate accountability are in question, such as the deaths and wider issues around Hillsborough and Grenfell Tower. Our policy, parliamentary, campaigning and media work is grounded in the day to day experience of working with bereaved people.

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