The inquest into the death of 23-year-old Sarah McGarrigle concluded on 25th October 2021 at Rochdale Coroner’s Court.

The Coroner, having made the decision at an earlier Pre Inquest Review Hearing that Article 2 of the ECHR was engaged, heard evidence from a number of medical professionals and social workers to establish how and in what circumstances, she came about her death.

She had been known to mental health services since childhood and had been detained under the Mental Health Act for a period of over 2 years whilst still a minor. Over time she had been given various diagnoses which included anorexia, Asperger’s, pathological demand avoidance and emerging borderline personality disorder. Sarah had a dependence on alcohol which had developed against a background of trauma and mental disorder.

Sarah was transferred to Aspen Ward on the evening of 22 January 2020 after receiving treatment for her physical condition. The mental health team responsible for assessing Sarah were provided with information about her history of involvement with mental health services, previous diagnoses, self-neglect, repeat and frequent calls to the ambulance service, disengagement with community services, moves between Liverpool and Oldham, and the concerns of her family and social care. The significance of this information was not fully appreciated by those assessing the Deceased on Aspen Ward who took her at face value. Sarah was discharged with a diagnosis of Mental and Behavioural Disorder due to Alcohol Dependency.

The Coroner concluded that there was no evidence to show that proper consideration was given to whether Sarah  had a mental disorder which impaired her capacity to make decisions in relation to treatment for her mental and physical health. She was discharged from Aspen Ward on 28 January 2020 and returned to her family in Liverpool.

By 24 February 2020, Sarah had returned to Oldham and was taken to the Royal Oldham Hospital on 26 February 2020 by paramedics in an intoxicated state, expressing thoughts of suicide. She was assessed by the Mental Health Liaison team and denied suicidal ideation. The Mental Health Liaison practitioner noted the outcome of the recent admission to Aspen Ward and found no evidence of acute mental illness and referred Sarah to the Community Mental Health Team.

Sarah had two further attendances to the Emergency Department at the Royal Oldham Hospital. The first was in  the early hours of 28 February, when she was brought in by paramedics having vomited blood. Upon arrival at the Emergency Department, Sarah informed clinicians that she wanted to leave. She was advised that the consequences of leaving without treatment may result in her death. She left the department after being assessed by a junior physician as having capacity to make the decision to decline treatment.

Sarah was returned to the Royal Oldham Hospital by paramedics at 18:46 hours on 28 February. She was intoxicated and had vomited blood. Upon arrival, she asked to leave the department and was assessed as lacking capacity to make that decision. Security were involved in preventing her leaving the department. At 01:30 hours on 29 February, Sarah was assessed by a Senior Registrar who considered that whilst she still had alcohol in her system she had the requisite capacity to leave against medical advice. She left the department at 02:10 hours on 29 February 2020 and was found deceased at her home address the following day.

The Coroner found that Sarah died as a consequence of the physical effects of alcohol dependency and self-neglect which had developed in the context of a long-standing mental disorder that had not been fully assessed and remained untreated at the time of her death.

Sarah’s family were represented at inquest by David Corrigan of Farleys Solicitors and Arevik Jackson of Kings Chambers.

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