27 January 2022

Before HM Assistant Coroner Robert Sowersb
Avon Coroner’s Court
17 – 27 January 2022

Zoe Wilson was 22 years old when she died a self-inflicted death whilst a voluntary patient on Larch mental health ward in Callington Road Hospital, Bristol on 19 June 2019. The jury inquest into her death has today returned a narrative conclusion that multiple failings by Avon and Wiltshire Mental Health Partnership NHS Trust contributed to her death, including:

  • The inadequate steps taken to keep Zoe safe on Larch unit after she handed in her belt on 17 June and stated that she was hearing voices telling her she should kill herself
  • The inadequate communication and information-sharing about Zoe between the staff looking after her on 17 – 19 June 2019
  • The inadequate observation of Zoe at around 1am on 19 June 2019, which was the primary mechanism of keeping her safe on Larch Unit

Zoe was a brilliant and beautiful young woman who was deeply loved by her mother, father, sister and all her family. In 2018, when Zoe was in her final year of a law degree at Exeter University her mental health deteriorated, and she developed delusional behaviour with episodes of psychosis. She returned home to her family in Bristol who had great difficulty in securing effective medical support for Zoe’s illness.

Later in 2018, Zoe was admitted as a detained inpatient to Callington Road Hospital. In September 2018, she was discharged into the community in Bristol and put under the care of the local Early Intervention Service.

In April 2019, following a further decline in Zoe’s mental health, she was detained on an acute ward in Callington Road Hospital where she remained until 6 June 2019.

Despite her ongoing psychosis, Zoe was then transferred to a low-risk ward at the hospital, Larch Unit. On 17 June 2019, she handed in her belt to staff because voices in her head were telling her to kill herself. Her room was not searched for any other ligatures following that disclosure, nor was that information properly handed over to staff on subsequent shifts.

In the early hours of 19 June, during twice hourly observations, Zoe was found standing beside her bathroom door looking scared but was not spoken to by staff. She was found ligatured thirty minutes later. Emergency services attended who pronounced Zoe dead.

Zoe’s family, said: “Zoe was a wonderful, bright, and deeply vulnerable young woman. She was on a low-risk ward by the Trust even when she told staff that voices in her head were telling her to kill herself. Her bedroom was not searched for ligatures even when she told staff she was worried that she was going to hang herself with her belt. She was not spoken to by staff even when was found standing beside a ligature point looking scared in the middle of the night. Minutes later she hanged herself.

Avon and Wiltshire Mental Health Partnership NHS Trust must now face a criminal prosecution by the Care Quality Commission for its breaches of health and safety legislation, which led to Zoe losing her life at just 22 years of age. We will continue to fight for justice in her name. She will never be forgotten.”

Tony Murphy of Bhatt Murphy solicitors, who represent the family, said: “The family now await the CQC’s investigation into the Trust. Time is of the essence as the three-year anniversary of Zoe’s death approaches in June. “

Selen Cavcav, Senior Caseworker at INQUEST, said: “Zoe’s escalating mental health crisis should have rung alarm bells for the clinicians and other staff who were in charge of care. The fact that she was failed in this way in a mental health unit which was supposed to keep her safe is utterly shameful.

The helpful jury conclusions in this inquest are also echoed in the internal investigation (a Root Cause Analysis) carried out by the Trust. However, the coroner refused to show this to the jury. We demand that the findings of this investigation are made public with clear action plan on the implementation of recommendations. It is only through complete transparency and candour can the learning come out of such preventable deaths."


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

The family are represented by Tony Murphy and Erica San of Bhatt Murphy solicitors and Stephen Clark of Garden Court, an INQUEST Lawyer Group member. The family are supported by INQUEST caseworker Selen Cavcav.

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

Other Interested persons represented are Avon and Wiltshire Mental Health Partnership NHS Trust.

Other recent cases:

  • The inquest into the death of student Natasha Abrahart in 2018 found failures in the actions of Avon and Wiltshire Mental Health Partnership NHS Trust. See media release, May 2019.
  • Alexandra Greenway, a 23 year old transgender woman from Bristol, died on 11 May 2019 whilst under the care of Avon and Wiltshire Mental Health Partnership NHS Trust. There was evidence of issues around a lack of access to treatment, including following a suicide attempt the month before her death. See media release, October 2020.