8 March 2019

Before HM Assistant Coroner Mr John Taylor  
West London Coroner’s Court
Inquest from 25 February to 6 March 2019

Charlotte Ball, 27, was found dead in her flat on 14 December 2017, after she failed to return from home leave whilst a patient at a mental health ward in South West London. An inquest into her death concluded on Wednesday 6 March, with the jury finding a range of critical failures by South West London & St George’s Mental Health Trust staff, which caused or contributed to Charlotte’s death.

The cause of death related to an overdose of a potentially lethal substance which she had purchased on the ‘dark web’. Charlotte had a diagnosis of Emotional Unstable Personality Disorder. She had a history of suicide attempts, including a near fatal attempt using the same substance in June 2017, which resulted in admission to the same ward.

Charlotte’s family describe her as a creative, intelligent and audacious person. They were heavily involved in her care, despite a consistent lack of communication with the family by NHS staff. The inquest heard about her mother’s serious concerns about Charlotte’s ability to mask her symptoms, and her attempts to be heard by the ward staff and Responsible Clinician. 

At the time of her death Charlotte was a voluntary inpatient on the Lilacs Ward in Tolworth Hospital, Kingston. She had initially been admitted to the ward and detained for assessment under section 2 of the Mental Health Act on 6 December, following an overdose of her prescription medication.

The detention was rescinded by the Responsible Clinician on 11 December, just days before Charlotte was found dead. The Clinician said he made this decision, in large part, because Charlotte had agreed to remain on the ward as a voluntary patient. Her family were not consulted or informed, despite well-established NHS policy on involving the families of mental health patients in care. Charlotte’s risk of self-harm throughout this time remained recorded as high and no care plan had been instituted, despite clear Trust policy on care planning.

On 13 December, Charlotte left the hospital for home leave. Contrary to clear Trust policy, the time of her leaving the ward, where she was going, and the time that she was due to return was not recorded anywhere. The inquest heard that Charlotte was generally expected to return by 5.00pm. Charlotte’s named nurse became concerned around 6.00pm and phoned her, with no response. It wasn’t until after 9.00pm on 13 December that the police were notified that she was missing.

Charlotte’s family were not notified by the ward at any stage. Her mother was only told she was missing the following day at around 9.30am, by Charlotte’s community care co-coordinator.

Over the next 24 hours, the police conducted a missing person’s enquiry. Officers visited Charlotte’s flat on multiple occasions but did not use their power of entry (under s.17 PACE). On the night of 14 December, in contrast to the previous officers, two other officers arrived and formed the view that they did have sufficient powers of entry. They entered the flat, where Charlotte was found dead. 

After hearing evidence over six days, the jury found the following factors as being probably causative of Charlotte’s death:

  • Insufficient assessment, monitoring and recording of Charlotte’s mental state from the date of her admission onto the ward.
  • Inadequate consideration of Charlotte’s full patient history when deciding to rescind the section on 11 December 2017.
  • A lack of consultation with Charlotte’s family regarding insight into her behaviour and future plans.
  • Inadequate recording of the details of Charlotte’s leave on 13 December 2017, contravening Trust policy and leading to no clarity on her expected return time to the ward which impacted the timing of reporting Charlotte missing to the Police.

The Jury also found that the following factors were possibly causative of Charlotte’s death;

  • Inadequate co-ordination of information gathering at the outset of the investigation by the Police.
  • Failure by the Police to communicate information between the station and patrol teams as the investigation progressed.
  • Failure by the Police to communicate with Charlotte’s family throughout the investigation.
  • Failure of multiple Duty Officers to adhere to the Missing Person Policy outlined at the time to review the risk and ensure progression of the investigation at the start of each shift.

Following this conclusion, the Assistant Coroner was satisfied that the Trust had made significant changes to relevant processes. He will be writing to the police to seek clarification about the gap between policy and practice in missing person’s investigations.

Dr Clare Jackson, Charlotte’s mother said: “Charlotte was let down by what seems like a culture of complacency and ignorance with regard to long standing and basic procedures to protect the safety of patients. Charlotte was wonderfully creative, powerfully intelligent and audacious. We are devastated by our loss.”

Gemma Vine of Minton Morrill said: “The record keeping and other errors in Charlotte’s case took place despite there being clear Trust policy on informal leave, risk assessments and care planning. Further the NHS policy commitment to a “triangle of care” in mental health settings, where the patient’s family’s views are to be valued, is well established. Once more we see a glaring gap between policy and practice with no real explanation as to why.”

Deborah Coles, Director of INQUEST, said: “The stark failings highlighted by this inquest are all too familiar. Women diagnosed with emotionally unstable personality disorder are frequently and repeatedly let down by mental health services. The recent review of the Mental Health Act echoed INQUEST’s concern that there is no national oversight on deaths in mental health settings. It recommended that a new body is set up to monitor and implement findings from inquests. This change is urgently needed to end repeated failings and preventable deaths like Charlotte’s.”



For further information, please contact Lucy McKay on 020 7263 1111 or [email protected]

INQUEST has worked with the family of Charlotte Ball since January 2018. The family is represented by INQUEST Lawyers Group members Gemma Vine and Anya Campbell of Minton Morrill, Leeds and Counsel Maya Sikand of Garden Court Chambers, London.

In December 2018, the Independent Review of the Mental Health Act 1983, chaired by Sir Simon Wessely, was published. The report endorsed the recommendation for an ‘Independent Office for Article 2 Compliance’, “tasked with the collation and dissemination of learning, the implementation and monitoring of that learning” from deaths.

Other relevant inquest conclusions:

  • Catherine Horton, 49, was an inpatient in South London and Maudsley (SLAM) run Bethlem Royal Hospital. She died of self-inflicted injuries at her home in Croydon on 24 July 2017, two weeks after absconding. On 18 December 2018, the inquest into her death criticised police and mental health staff for failures amounting to neglect. See INQUEST media release.

  • Emma Butler, 33, died on 30 March 2017 after being sectioned as an in-patient on the Ruby Ward, Whiteleaf Centre, under the care of Oxford Health NHS Foundation Trust. She was diagnosed with Emotionally Unstable Personality Disorder. On 6 December 2018 the inquest into her death concluded, with the jury critical of the care and decision making which allowed her unsupervised leave, despite evidence of her risk of self-harm. See INQUEST media release.

  • Ellie Brabant, 28, died a self-inflicted death whilst an inpatient at Antelope House, a mental health unit in Southampton, on 2 November 2017. She had a diagnosis of Emotionally Unstable Personality Disorder. On 12 November 2018, the coroner concluded that the lack of a clear care plan, and the decision to discharge Ellie from Section 3 of the Mental Health Act more than minimally contributed to her death. See INQUEST media release.

  • Sophie Payne, 22, died whilst detained as a mental health patient on the Rose Ward at Queen Mary Hospital in Roehampton. She had been diagnosed with bipolar disorder and emotionally unstable personality disorder. In July 2018 the inquest into her death found a series of significant failings contributed to her death. See INQUEST media release.

  • Katie Hamilton, 26, died in hospital, three days after being found unconscious with a ligature whilst a secure mental health inpatient at the Becklin Centre in Leeds on the 9 March 2016. She was diagnosed with Emotionally Unstable Personality Disorder. On 15 December 2017 an inquest concluded finding she did not intend to take her own life. See INQUEST media release.