20 November 2020

Before HM Assistant Coroner Anna Crawford
Surrey Coroner’s Court
9 – 20 November 2020

Kimberley Ann Smith was 33 when she died while a mental health inpatient in Surrey on 13 October 2018. The inquest has today concluded finding that neglect contributed to her death by suicide.

Kimberley was an inpatient at Anderson Ward, a mental health ward for women at the Abraham Cowley Unit (ACU) in St Peter’s Hospital, Chertsey and operated by the Surrey and Borders Partnership NHS Foundation Trust (SaBP). Despite being at a high risk of self-harm and suicide, Kimberley was able to abscond on multiple occasions and access alcohol and materials for self-harm. She was placed under a short, temporary section that was allowed to lapse.

Kimberley was a bright, kind and generous young woman who had a promising career in fashion. She had struggled with self-harm since her teenage years, and in the three years before her death was diagnosed with mental and behavioural disorders due to alcohol, post-traumatic stress disorder, anorexia nervosa and emotionally unstable personality disorder.

Kimberley was admitted to the unit as an informal patient on 3 October 2018. She had recently been detained by Surrey Police under section 136 of the Mental Health Act 1983 on three occasions between 20 September and 2 October 2018, during a period of rapidly worsening mental health crisis. On two of those occasions Kimberley had made a serious attempt on her own life, after consuming alcohol.

Shortly after admission to the ACU, Kimberley was allowed to leave the ward and went on to consume alcohol. On 5 October 2018, Kimberley left the ward and become so intoxicated that she was taken to A&E by a passer-by. The following day she was detained for 72 hours on the ward (under section 5 of the Mental Health Act) due to concerns that she would leave to drink again.

An independent consultant psychiatrist instructed by the coroner, Dr Michael Isaac, told the inquest jury that, given the high risk of suicide Kimberley presented, at this point she should have been assessed and detained in the ACU under section 2 of the Mental Health Act (allowing up to 28 days of detention for assessment) for her own safety. However, Kimberley’s temporary section was instead allowed to lapse on 9 October without a further Mental Health Act assessment. She then absconded from the ward for a second time on 10 October 2018 and was brought back very intoxicated in the early hours of 11 October in the company of an unknown man.

An instruction was then entered into Kimberley’s medical records that she was to be risk assessed before being allowed to go on any leave. She had also been assessed as high risk of suicide when under the influence of alcohol. Yet the following day (12 October) the level of observations for Kimberley were reduced from every 15 minutes to hourly, with no documented reason as to why. She was allowed to leave the ACU at 3.20pm unescorted – again without any risk assessment taking place.

The two nurses in charge of Anderson Ward that day were both bank nurses who had no understanding of Kimberley’s risks or history. Although Kimberley agreed to be back at the ward by 4.30pm, she did not return – yet no action was taken by the day staff at the ACU. At around 7.30pm that evening the unknown man called nurses to say he was concerned about Kimberley as she was talking about suicide. At around 10.30pm, ACU night shift staff eventually made contact with Kimberley and noted that she was tearful and intoxicated.

Shortly after midnight, the man who was with Kimberley returned her to the ACU. The man walked from the car park towards the ACU to hand Kimberley’s bag, which contained two bottles of spirits, numerous packets of medication, string and razor blades, over to staff. However, Kimberley walked off in the opposite direction. Following this, at 12.10am on 13 October, a nurse reported Kimberley as a missing person to Surrey Police. No Missing Persons ‘pack’ had been completed to enable accurate details to be passed to the police (which staff were obliged to do upon her admission); and the police were told that Kimberley was an ‘amber’ (or moderate) risk.

It was approximately seven hours before Surrey Police deployed an officer to the ACU in response to this call. Kimberley was seen alive by other patients on the ward at around 2pm, but no enquires were made of her peers. At approximately 4.45pm on 13 October, Kimberley’s body was discovered by other patients in a wooded area on the hospital grounds less than 100 yards from the main entrance of the ACU, which was reported to have been an unofficial smoking area for patients and staff.

After six days of evidence and three days’ deliberation the jury concluded that Kimberley’s death was by suicide, the medical cause of which was asphyxia with the jury finding the following factors contributed to her death.

  • The care planning and risk management in relation to Kimberley’s use of alcohol and the risks she posed to herself if she left the ward and consumed alcohol were inadequate;
  • The failure to assess and detain Kimberley in hospital under the Mental Health Act on either 8 or 11 October 2018;
  • The decision to allow Kimberley to go on unescorted leave from Anderson Ward after 11 October 2018;
  • The failure of nursing staff to carry out an adequate risk assessment prior to the decision to allow Kimberley Smith to leave the Abraham Cowley Unit at 3.20pm on 12 October 2018;
  • The failure of the staff on duty on the Abraham Cowley Unit on the day shift to activate the missing person protocol on 12 October 2018 before the end of their shift;
  • The failure of the staff on duty on the Abraham Cowley Unit on the night shift to activate the missing person protocol on 12 October 2018 following a telephone call to the ward at approximately 7.30pm.

The jury also concluded that the following factors possibly contributed to Kimberley’s death:

  • The decision to reduce the level of observations on Kimberley Smith from every 15 minutes to hourly on 12 October 2018;
  • A failure by the staff on duty on the Abraham Cowley Unit on 13 October 2018 to make fellow patients aware that Kimberley Smith had not returned to the ward since the previous day;
  • The information available and provided to the police by the Abraham Cowley Unit nursing staff when she was reported missing at 12.10am on 13 October 2018, including the lack of a completed Missing Persons Pack, was inadequate;
  • The recording of the information on Surrey Police’s ICAD that was obtained during a phone call from Surrey Police at 1am on 13 October 2018 with a witness, was inadequate; and
  • The absence of any warning markers on the Police National Computer or the Surrey Police NICHE System with regards to the three recent incidents which had resulted in Kimberley Smith being detained by the police under s.136 of the Mental Health Act.

The majority of the jury concluded that Kimberley’s death was caused by neglect – that is, gross failures to provide her with basic care.

The Assistant Coroner for Surrey, Anna Crawford, indicated that she would be writing a Prevention on Future Deaths report in relation to her ongoing concerns around leave being granted to patients at the ACU, and the Trust’s policies for reporting missing patients to the police.

The Mental Health Strategic Lead for Surrey Police, Lee Sawkins, described it as “concerning” that no suicide warning markers had been placed on the Police National Computer for Kimberley Smith, given her recent history of involvement with the police and the risks she presented. The Surrey Police suicide prevention force advisor is currently developing a system whereby the force can record risk relating to attempt suicide on local and national police systems.

David Smith, Kimberley’s father, said: “We knew in the weeks leading up to Kimberley's death that there were increasingly serious issues with Kimberley’s care. We tried to raise these concerns to the best of our ability at the time. On 3 October 2018 we watched our daughter leave for the ACU believing that she would be in a place of safety, optimistic and hopeful for her care and well-being. Ten days later Kimberley took her own life.

We are shocked and angered by the evidence that we heard at Kimberley’s inquest, and feel so desperately saddened and upset that Kimberley, at a time of crisis and need, was placed in this environment and that more urgent action was not taken to keep her safe. The jury’s Neglect conclusion only exacerbates our pain and deep sense of loss. It brings little sense of closure around the tragic circumstances and untimely death of our beautiful daughter, particularly in the knowledge that the concerns we voiced at the time were in fact justified, but were inadequately acted upon – and that Kimberley’s death could and should have been prevented. We miss you Kimberley more than you will ever know, you are forever in our hearts and thoughts.”

Elaine Macdonald of Tuckers Solicitors said: The evidence heard during this inquest highlighted a litany of shocking failures in the care provided to Kimberley at the ACU, including a lack of coherent information being shared between the Trust and Surrey Police at critical times while Kimberley was missing from the ward and should have been considered to be at high risk. Kimberley was badly let down, and lessons need to be learned.”

Deborah Coles, Director of INQUEST, said: “Kimberley’s experiences, and the ways in which she has been seriously failed and neglected, are reflective of significant issues across the country. There are widespread shortcomings in mental health services providing care for young women, particularly those with multiple diagnoses which are seen as complex, such as personality or eating disorders. In this unit itself, five years ago a coroner warned the Trust that they needed to address the monitoring of those leaving the building, after another patient absconded and died. This recommendation was made to prevent future deaths, but clearly not enough has changed. Locally, SaBP must do more to address their continued failings, and nationally the system must change to ensure potentially lifesaving recommendations are enacted and sustained.”


For more information contact INQUEST Communications Team on 020 7263 1111 or [email protected] A photo of Kimberley is available here.

The family is represented by INQUEST Lawyers Group members Elaine Macdonald of Tuckers Solicitors and Tom Stoate of Garden Court Chambers. They are working with INQUEST Caseworker Bola Awogboro.

Other interested parties were Surrey and Borders Partnership NHS Trust, Surrey Police, and the Independent Office for Police Conduct.

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

Issues at Abraham Cowley Unit:

  • In 2015, a coroner expressed concerns about the ability of patients to leave the secure wards at Abraham Cowley Unit after an inquest was told a new lock was not sufficient in preventing inpatients from leaving the ward. The coroner told the Trust to “address the closer monitoring of those leaving the building” to prevent future deaths.
  • This was following the inquest into the death of Simon Tree, who was a voluntary patient at the Abraham Cowley Unit, having originally been sectioned. He’d been returned to the unit by police after being found by the River Thames in a state of intoxication, expressing suicidal thoughts. He was due to be re-assessed, but subsequently managed to leave the unit and was found dead on 18 February 2012 in the River Thames having drowned.
  • In September 2020 the Care Quality Commission told Surrey and Borders NHS Foundation Trust that it must make improvements to its acute wards for adults, following an inspection of two of the wards at the at the Abraham Cowley Unit. This followed the deaths of two patients on the Clare Ward in April and May 2020. High risk patients were then only being admitted to the Blake and Anderson wards.

Recent Surrey and Borders Partnership NHS Foundation Trust (SaBP) cases:

  • Last year an inquest into the death of Sasha Forster, 20, identified failures in SaBP crisis care planning, and a failure to recall Sasha from leave. The inquest concluded her death whilst on leave from Farnham Road Hospital was a suicide. Media release
  • Bruce Simpson, 53, died a self-inflicted death in Abraham Cowley Unit on 10 March 2018. An inquest in 2019 identified multiple failures, including in observations and care planning, as well as his placement in a room with ligature points. Media coverage
  • In 2017 SaBP were sentenced to a fine of £300,000 after pleading guilty to maintaining an unsafe environment at the Langley Unit mental health facility. That failure led directly to the death of Adam Withers, aged 20, in May 2014. Media release

National Oversight Mechanism on deaths in detention
INQUEST have long campaigned for a national oversight mechanism which would monitor and audit recommendations of the various investigations and inquests which follow deaths in places of detention. While this has been supported in parliamentary inquiries and independent reports, we are yet to see steps towards a national oversight mechanism, which INQUEST believes would help ensure recommendations arising from deaths are enacted and change is sustained.