25 April 2023

Before HM Assistant Coroner for Surrey, Darren Stewart OBE
Surrey Coroner's Court
11 April 2023 - 24 April 2023

Meghan Chrismas, 48, died a self-inflicted death on 20 October 2021. At the time of her death, Meghan was being treated as a missing person by the police.  Yesterday, the inquest into her death concluded and found that the communication method used between police forces involved was inappropriate.

Meghan was born in Australia, to a large family. When travelling around Europe, she met her future husband, James. She stayed in the UK and started her family. Meghan is described by her husband as "the most amazing mother" to their two young children and a “wonderful person and her ability to make everyone feel comfortable, secure and loved were her greatest strengths”.

Meghan experienced a decline in her mental health in July 2021, after a panic attack whilst out with friends. Following this, Meghan was a voluntarily inpatient at the Priory Hospital in Roehampton. After her discharge, Meghan continued to see a consultant psychiatrist as well as a psychotherapist, who provided Eye Movement Desensitization and Reprocessing (EMDR). Meghan had informed her GP that she was seeking this assistance privately. Evidence at the inquest suggested that it was possible Meghan had access to two sources of prescriptions from both her private psychiatrist and her GP.

Over the following months, Meghan’s mental health continued to deteriorate. On 1 October 2021, Meghan drove from her home and took an overdose of medication. She eventually returned home the following morning, where an ambulance was contacted.

She was admitted to the Royal Surrey Hospital the following day, where she was assessed by Psychiatric Liaison Services. During this assessment, Meghan explained that she was receiving treatment from a private psychiatrist and psychotherapist. Meghan was discharged the following day.

Her private psychiatrist would often send monthly prescriptions of the medication. After this overdose, the GP reduced his prescriptions to a weekly supply of medication. Evidence was also heard as to how Meghan's GP did not inform her private psychiatrist about this overdose. In her evidence at the inquest, Meghan's private psychiatrist stated that this was extremely significant information that should have been passed onto her.

Meghan’s husband became incredibly worried about Meghan’s mental health and made contact with her GP to express his concerns. On 12 October 2021, the GP made a referral to Surrey and Borders NHS Trust for an urgent mental health assessment.  The referral was refused on the basis that it was made without Meghan's knowledge or consent. The matter was sent back to the GP for a further assessment with Meghan as well as for her consent for a referral to be obtained. Evidence heard at the Inquest indicated that – had consent been obtained from Meghan – their support would have likely been provided.

Despite making this referral, Meghan's GP did not inform her private psychiatrist of escalating concerns about Meghan's mental health.

On 18 October 2021, Meghan left her family home and that afternoon, sent text messages to her husband stating that she was going to take her own life. Her husband called 999 at 16:34 and reported these concerns to Hampshire Police. The call was marked as a Grade 1 missing person.

Initial investigative steps by the police revealed that Meghan was at a Premier Inn in Guildford, Surrey. At 17:18, a controller in Hampshire police emailed Surrey police to request their attendance at the Premier Inn. An Inspector from Hampshire police stated to send an email was clearly the wrong course of action in the circumstances. The evidence suggests Hampshire police officers on the ground were unaware an email was sent.

Almost an hour later – Hampshire police called Surrey police by telephone following which officers were deployed.

Meghan’s last communication was a text message to her family at 18:19.

By the time Surrey police officers reached Meghan’s room, she was already unconscious and had to be urgently resuscitated.

Meghan was transported to Royal Surrey Hospital, and died on 20 October 2021.

The jury concluded that:

• There appeared to have been confusion with respect to Meghan's risk status. Police officers acted under the impression the incident was indeed high risk, but the incident log described the risk as low.
• Hampshire police communicating with Surrey police by email, rather than telephone was inappropriate in light of the reality of the incident.

There is going to be a further hearing to address issues relating to Prevention of Future Deaths. This will address the passage of information between NHS and private healthcare providers, and the handling of the missing person incident by Hampshire police in an hour delay in determining an important communication had not been received by another force.  The family hopes this will ensure changes will be made.

James Chrismas, husband of Meghan, said: “I was desperately trying to get Meghan help. I feel let down by both the practitioners and by the police force, saddened by what I see to be systemic failures. In my view, the inquest has shown flaws in the transfer of information between health practitioners in the months before Meghan’s death, and the cross border communication from Hampshire Police to Surrey Police on 18 October 2021.

My family has been seeking answers and I really do not want anyone else to suffer what we have, and be in the same situation.”

ENDS

NOTES TO EDITORS

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

The family is represented by INQUEST Lawyers Group members Mollie Eglesfield of GT Stewart Solicitors, and Matthew Turner of Doughty Street Chambers.

Other Interested Persons represented include: Hampshire Constabulary, Surrey Police, Surrey and Borders NHS Foundation Trust, the Priory, Meghan's GP, Meghan's psychiatrist, and a controller from Hampshire Police.