The inquest into the death of Julianne Simpson was held recently at Heywood Coroner’s Court in Great Manchester. The jury heard that Ms Simpson had died by accident after choking on a 60ml medication pot in which her medication had been given to her.

At the time of her death, Ms Simpson was a detained patient at the Edenfield Centre while she was awaiting a transfer to Rampton Hospital. While being kept in seclusion, she exhibited a number of symptoms of paranoid schizophrenia including serious self-harming behaviour. As a result of her self-harming behaviour, she was prevented access to virtually every item due the high level of risk she posed to herself.

The jury heard that despite this, there had been a failure to document the way in which medicine would be given to Ms Simpson and there was no adequate risk assessment of the 60ml pot. They found the use of that specific pot to administer the medication inappropriate. As well as the findings by the jury, the coroner has announced that she will be making recommendations on the subject of the availability of larger medications pots and the procedures involved in transferring patients into high security hospitals.

Ms Simpson’s family were represented by Kelly Darlington, head of Inquests at Farleys Solicitors and Stephen Simblet of Garden Court Chambers.