7 October 2021

Before HM Coroner for Gwent, Caroline Saunders
Gwent Coroner’s Court
4 to 7 October 2021

The inquest into the self-inflicted death of Sarah Price, a patient at St Cadoc’s hospital in Newport, has concluded today. The jury returned a critical narrative conclusion and a finding that neglect contributed to Sarah’s death on 2 February 2016.  

Sarah was 23 years old. She was a bubbly, funny and friendly person and part of a large and close-knit family.  She had complex mental health needs which started when she was a child, and a learning disability which affected her ability to understand others. She was bullied at school and started self-harming.

In November 2015, Sarah was detained under the Mental Health Act after she attempted to take her own life using an item in her supported living house. She was admitted to St Cadoc’s hospital, run by the Aneurin Bevan University Health Board. She remained there until her death three months later.

In the days before her death, Sarah reported she was hearing voices, getting louder and louder, telling her to suffocate herself. She made several attempts to access items, like those she used previously, to do this. Staff witnessed this and yet the items were not removed from any part of the ward and Sarah’s risk assessment was not updated.

The jury found that on the day of her death staff downgraded her observations, from constant observations to intermittent only, without fully taking into account her risk to herself. They found that her death was contributed to by neglect.

Sarah’s mum Rachel Price said on behalf of the family: “Sarah was profoundly let down by the Aneurin Bevan University Health Board when she was most in need. Our family thank the jury and our legal team. We have fought for justice for Sarah for since her death in 2016 and justice has finally been done.”

Selen Cavcav, senior caseworker at INQUEST, said: “This is the third inquest in the past few weeks to identify issues around mental health patients accessing the same potentially dangerous items. Families expect that mental health units are the safest place for their loved ones, yet too often that is not the case.

 It is welcome that this inquest has identified the serious failings in Sarah’s case. There is a clear need for a new national policy on restricted and dangerous items to prevent deaths in future. This, alongside adequate and skilled staffing, is essential to ensure patients are kept safe.”


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

The family are represented by INQUEST Lawyers Group members Clare Richardson from DPG solicitors and Kirsten Heaven of Garden Court Chambers. They are supported by INQUEST caseworker Selen Cavcav.

Other Interested persons represented are the Aneurin Bevan University Health Board.

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