Before Senior Coroner for Essex, Caroline Beasley-Murray OBE
Essex Coroner’s Court Chelmsford
9 November – 12 November 2020

The inquest into the death of Sharon Kelly concluded yesterday, finding that failings by East of England Ambulance Service and Essex Police contributed to her death. The jury concluded that the timing of the Mental Health Act assessment was inadequate, the ambulance service failed to initiate a risk assessment when arriving at the scene and that there was wide spread miscommunication between all services. Sharon’s death was found to be suicide.

Sharon was 44 years old when she died on 27 June 2019 after she was found hanging by Essex Police and paramedics at her home in Colchester. It took nearly three and a half hours from an initial call for paramedics to enter Sharon’s home. Sharon had a history of mental ill health and was under the care of Essex Partnership University Foundation Trust (EPUT) at the time of her death. 

The inquest heard evidence that two days before Sharon’s death, an EPUT psychiatrist had urgently requested a Mental Health Act assessment, following concerns raised about her welfare. This psychiatrist, who had been involved in Sharon’s care since 2016, said he had expected a Mental Health Act assessment to be carried out the same day the referral was made. The assessment was not carried out until the next day, when it was decided that Sharon did not, at the time of that assessment, meet the statutory criteria to be detained under the Mental Health Act.
 
On 27 June at 1.45pm, Sharon’s daughter rang the Ambulance Service after serious concerns were raised about her wellbeing. An ambulance arrived on the scene at approximately 3.30pm but the crew did not enter Sharon’s property due to the ‘warning flag’ on the address following a previous incident. It is common practice that with such a marker on the address, the ambulance crew would carry out a risk assessment at the scene before deciding whether they need police assistance. The ambulance crew parked at a distance from the property and the crew decided to wait until police attended. They waited for more than an hour before being reassigned as the police could not provide an ETA. At no point did they approach Sharon’s house.
 
The Ambulance Service recognised a lack of clarity over the risk assessment and decision making process regarding call-outs to an address where there is a ‘warning flag’ on the system and that further information should have been provided to the ambulance crew on scene, including that the crews had attended Sharon’s address the day before without issue.
 
The inquest heard that it took over an hour to allocate an available police unit to the incident. The Police eventually arrived on scene at around 5pm, followed by an ambulance shortly after. The Chief Inspector in charge of the Essex Police Control Room explained that a significant portion of the delay was unaccounted for in the police logs and that this incident had highlighted shortcomings the system for processing calls. The police and ambulance service gained entry to Sharon’s property at about 5.12pm and found her hanging. Efforts were made to resuscitate but Sharon was pronounced dead at 5.22pm.

Susan Walkinshaw-Kelly, Sharon’s mother said: “Sitting through the four days of evidence and legal submissions was a very harrowing experience. It confirmed for me my fears that there were multiple failures by the services involved and that these may have contributed to Sharon’s death. However, I can at least take some comfort that the jury identified numerous failings and brought them to light in their conclusions. Hopefully, appropriate changes will be made and implemented to ensure such a needless tragedy does not happen again.”

Deborah Coles, Director of INQUEST said: “Sharon’s death could and should have been prevented. All the warning signs were there yet failures by the mental health team and later by the police and ambulance service meant Sharon had no support when she was most in need. Women are repeatedly failed by mental health services and the lack of gender informed specialist provision. Essex mental health services in particular have a dismal record in regard to the care of mental health patients." 

David Gabell of Fosters solicitors said: “It was a privilege to represent the family in this tragic case. The family has shown immense bravery throughout the entire inquest process. The family had felt that there were real concerns to be raised across various state agencies regarding the circumstances leading up to Sharon’s death, and the jury’s findings today confirm their concerns were entirely valid. I am immensely glad that we have been able to assist the family through this complicated and often distressing case and get them the justice they deserve.”

ENDS

For further information, interview requests and to note your interest, please contact INQUEST Communications Team: 020 7263 1111 or [email protected]. A photo of Sharon is available here.

The family is represented by INQUEST Lawyers Group members David Gabell of Fosters Solicitors and Jon Metzer of 1 Crown Office Row. The family are supported by INQUEST caseworker Bola Awogboro.

The other Interested Persons represented at the inquest are East of England Ambulance Service NHS Trust, Essex Partnership University NHS Foundation Trust and the Chief Constable of Essex Police.

Sharon’s family have joined forces with 24 other families across Essex to demand a public inquiry into the deaths of people under Essex Mental Health services. A debate is taking place in parliament on 30 November 2020 following a successful petition by Melanie Leahy.

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