On 1st October 2021, HHJ Sephton QC gave his Judgment after a five-day trial at Manchester County Court awarding £20,000 in damages to four claimants. The claimants were the bereaved sisters of 28-year-old Julianne Simpson (“JAS”) who choked to death on 2nd March 2017 on a 60ml plastic medication pot while under the care of the Trust (“The Defendant”). A declaration was made that the Defendant violated its positive obligation under Article 2 ECHR to protect the life of their sister.


At the time of her death, JAS was a detained patient at the Edenfield Centre, Manchester which is a medium secure unit. She had been placed in seclusion settings due to the serious risk she posed in harming herself and others, with fatal consequences. This included fashioning ligatures and self-harming by swallowing items. Since September 2015, and until her death, the complexity of JAS’s needs and presentation were such that it was thought appropriate by those in charge of her care that she should be in the most secure psychiatric hospital in Britain, Rampton Hospital.

On 1st March 2017, JAS was administered medication in a 60 ml plastic medication pot when, without warning, she squashed the pot in her hand and forced it into her mouth, which caused her to choke.

How Farleys were able to help

Our specialist inquest team represented the Claimants in the inquest proceedings into JAS’ death. The Jury made criticisms about the risk assessment of the 60 ml pot and the failure to document the method of administering medication in JASs care plan.

Following evidence provided by the Defendant as part of the inquest process after JAS’s death, and from evidence given on oath by witnesses employed by the Defendant at the inquest, the Claimants were advised to pursue a claim against the Defendant.

It was alleged that there was no formal risk assessment of the plastic cup to be used, or any detailed consideration by JAS’ responsible clinician or ward manager in charge of her care of any risks associated with the plastic cup. At no point did the formal management plan in relation to JAS instruct staff to use any particular receptacle for administering medication to her, save it stated that paper cups should not be used. It was the Claimants’ case that JAS died because she was able to use the only item in her room that had not been the subject of a proper risk assessment to choke/injure/kill herself.

The Defendant was invited at the outset to admit that at all material times it knew or ought to have known of the existence of a real and immediate risk to JAS’ life such that the Defendant breached JAS’s right to life under Article 2 ECHR, the Claimants’ rights to private and family life under Article 8 ECHR, and also breached their duty of care owed to JAS and were negligent in all the circumstances.

The Defendant fiercely defended the claim from the outset resulting in a five-day trial to determine liability and damages. This was despite the Claimants inviting the Defendant to negotiate settlement of the claim very early on so they did not have to endure the further stress, anguish and upset of a further three years of litigation.

We instructed expert evidence from a Forensic Psychiatrist in support of the claim and the Court accepted the evidence of the Claimants’ expert that the Defendant did not undertake a critical analysis of whether the change in administering medication to a 60ml plastic cup presented a choking risk.

The Outcome

After hearing evidence from two psychiatrists, a nursing expert, and the Defendant’s witnesses responsible for JAS’ care, the Judge concluded that the decision to change the cup was a serious matter that required proper consideration and critical analysis of the pot and the risk. The Judge found that whilst the threshold for breach of Article 2 is difficult, he would nevertheless conclude that the Defendant did not do all that it reasonably could in its operational duty and the necessary scrutiny was not given, and that led to the tragic death of JAS.


The Court observed that it was clear that JAS was very unwell and it is likely she would have been admitted to Rampton Hospital giving very little prospect of the Claimants being reunited with her in the future. The Defendant sought to argue that JAS was the author of her own misfortune which the Court rejected. The Judge commenting that the idea that JAS had done a voluntarily action was inaccurate and distasteful.

The Claimants’ were awarded £20,000 in damages and a declaration was made that their right under Article 2 had been violated by the Defendant.

The same legal team dealt with both cases as follows:

Kelly Darlington, Head of Inquests, Farleys Solicitors

Stephen Simblet QC, Garden Court Chambers