14 January 2022

Before HM Assistant Coroner Rob Sowersby and a Jury 
Avon Coroner’s Court, sitting in person
at The Arts Mansion, Ashton Court, Kennel Lodge Road,
Bristol BS3 2JT (pre-booking required)

Opens 17 January 2022 - Scheduled for 6 -10 days

 Zoe Adrienne Wilson was just 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 inquest into her death will consider potential issues in the care she received from Avon and Wiltshire Mental Health Partnership NHS Trust.

Zoe’s family describe her as an intelligent, articulate and beautiful young woman who had a lot to offer. Zoe was in her final year of studying Law at Exeter University before her family became concerned about her mental health and she returned home to Bristol.

In April 2019, Zoe was admitted to the Silver Birch Ward in Callington Road Hospital, an acute admission facility, due to being severely unwell including with psychosis, where she remained until 6 June 2019.

Despite concerns from her family and some clinicians, Zoe was then admitted to the less intensive care of the Larch ward and plans were put in place for her future discharge into the community.

On 19 June 2019, Zoe was found having ligatured in her room on Larch ward. Emergency services were called and CPR commenced, but Zoe was pronounced dead.

The family hope the inquest will consider the importance in mental health services of:

  • Continuity of patient care;
  • Management of risks posed to patients, including from ligatures and ligature points;
  • Effective observation and staff engagement with patients;
  • Meaningful staff liaison with patients’ families.


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

The inquest is sitting with a jury in person and not virtually. Attendance at the hearing must be pre-booked by contacting Avon Coroner’s Court on 01275 461 924

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.

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

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

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.