Inquest jury finds neglect by NHS trust contributed to death of 24-year-old mother from Folkestone

22nd November 2016

Today, at an inquest into the death of Natalie Gray, a 24-year-old mother from Folkestone in Kent, a jury found that neglect by Kent and Medway NHS and Social Care Partnership Trust contributed to her death.


Natalie died on 21st April 2015 after jumping in front of a train at Barming station. She had a long history of mental health difficulties and was under the care of mental health services after attempting to take her own life on a number of occasions.


The jury at Kent and Medway Coroner’s Court concluded that there were a number of gross failings by the NHS Trust which amounted to neglect and contributed to Natalie’s death. These included making insufficient risk assessments, inadequate handovers between staff, failures to convey and enforce the correct procedures for informal patient leave to occupational therapists and failure of occupational therapists to follow those procedures.


The jury also found that the following failings may have possibly contributed to her death:


  • Delays in confirming it was Natalie who had left Priority House and commencing a search
  • Unnecessary delay in reporting to Kent Police that she was missing
  • Failure to provide Kent Police with relevant information
  • Failure to follow Trust Policy by not contacting next of kin


The jury noted that it was relevant to the circumstances of Natalie’s death that the Trust failed to record information provided to them by third parties, namely a concerned chaplain and Natalie’s aunt.


They also noted by a majority of 9:2 that the 999 call taker and the back-up police dispatch officer at Kent Police had failed to elicit the relevant information from the Trust.


Deborah Coles, Director of INQUEST said:

“The failure of Kent and Medway NHS and Social Care Partnership Trust to protect Natalie is truly shocking, especially given her well-documented vulnerability. Staff should have been aware of her repeated attempts to end her own life and vigilant to the possibility that she might cause herself harm. Instead, there was an utter failure to communicate the risk she posed to her own life.


Natalie’s death is another tragic reminder of the systemic failure to protect and support women in mental health crisis. Sadly, this is not an isolated case and points to the urgent need for government to invest in specialist, quality mental health services for vulnerable women.”


Roselin Sayer, Natalie’s aunt said:

“Natalie was a wonderful mother who loved her daughter and wanted the best for her. Losing her has left an enormous hole in our family. It has been a fight every step of the way to get to the truth of what happened to Natalie. We were still receiving new information half way through the inquest that shed light on the quality of her care at Priority House. We hope that lessons will be learned from Natalie’s case and that Priority House will take steps to prevent future deaths by conducting proper risk assessments and improving procedures for allowing patients off the wards to ensure that no other family has to go through this. I would like to add that throughout Natalie’s illness the police have been supportive and helpful in the family’s dealings with them.”


Alice Hardy, Hodge Jones & Allen solicitors said:

“Natalie had a troubled upbringing and had been suffering from mental health issues and self-harming since she was a teenager. Her family are devastated by her loss and are shocked by the failings of those responsible for her care. They believe she should not have been assessed as low risk given her escalating suicidal behaviour and loss of the protective factors in her life. The jury’s conclusion that Natalie’s death was the result of neglect by Kent and Medway NHS and Social Care Partnership Trust as a result of a catalogue of gross failings by Priority House in the days and hours before she died signals the need for significant changes in how the hospital cares for its vulnerable patients.”



INQUEST has been working with the family of Natalie Gray since April 2016. The family is represented by INQUEST Lawyers Group member Heather Williams QC, Doughty Street Chambers and Alice Hardy, a human rights lawyer at Hodge Jones & Allen.



Notes to editors:


Case history:


Natalie, who had experienced abuse as a child, had been having suicidal thoughts since 2012 and had subsequently split up with her partner. Shortly after this her father died. This combination of events left her feeling suicidal. By March 2015, she had attempted to kill herself several times.


On 8 April 2015, Natalie was admitted to Priority House, Maidstone Hospital.


On 17 April, 20 April and 21 April, Natalie was assessed as low risk despite having expressed clear intent to take her own life. Staff were not informed at handovers that Natalie should be reassessed if she became agitated and tried to leave the ward.


At approximately 3pm on 21 April 2015, Natalie became very distressed and expressed a wish to end it all. Shortly afterwards she was allowed to leave the ward by a member of occupational therapy staff without any risk assessment being conducted. On realising that Natalie had left the ward, staff delayed looking for her and contacting the police.


At approximately 6pm on 21 April 2015 Natalie was found dead at Barming train station.


For further information, please contact Anita Sharma (caseworker) or Gill Goodby (media) at INQUEST on 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.