Imani Rigg died on 8 July 2024, following an incident of self-harm three days after her discharge from the Richmond Home Treatment Team (‘RHTT’). The Coroner found that the risk to Imani’s life could and should have been appreciated by the mental health teams that were working with her, who were aware of Imani’s suicide plans for around five weeks before she tragically acted on them. The Coroner found that the repeated suggestion that Imani’s life was not at imminent risk was unsustainable and that the treatment Imani received from South West London and St George’s Mental Health NHS Trust possibly contributed to her death.
Imani was a much-loved daughter and sister who was precious to the people who knew her. Imani was highly intelligent and an accomplished primary school teacher who loved her work and was hugely popular with the children she taught. She spoke about them often and fondly, and teaching gave Imani energy and confidence.
Sadly, Imani experienced trauma in her life and she suffered a sexual assault in 2019 that caused her significant emotional pain. The Coroner found that when Imani started EMDR (Eye Movement Desensitisation and Reprocessing) therapy in March 2024 this destabilised her mental health and she began using medication to excess to numb painful feelings. In the months that followed, Imani was preoccupied with the upcoming 5-year anniversary of the assault in July 2024 and she told her psychologist that she did not want to continue living after it.
The Court heard that Imani had meticulously outlined all the factors that had contributed to the decline in her mental state in a pie chart, which was described by her consultant psychiatrist as impressive. They included the following:
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The ongoing impact of the trauma Imani had experienced and the fact that she was not able to continue EMDR therapy in the near future.
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The fact that Imani had been waiting for an ADHD assessment for around 2 years and was unable to obtain an assessment privately due to the complexity of her presentation.
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Imani’s physical health conditions and the pain they caused her.
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An ineffective medication regime.
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Worries about the transition back to the community mental health team (known as the Twickenham Integrated Recovery Hub ‘TIRH’) and the lack of any introduction to her care coordinator before their first face to face meeting on 5 July 2024, the day Imani was discharged from the RHTT.
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Strong suicidal ideation and Imani’s feeling that she was not ‘here’ and ‘had to go’.
On 12 June 2024, a serious incident occurred in which Imani told RHTT practitioners that she had ordered the item that she intended to use to take her life and was expecting to receive it imminently. On that occasion, a RHTT practitioner made an unannounced visit to Imani and decided to breach her confidentiality and immediately tell Imani’s mother and step-father that they needed to call the ambulance and police services, which they did. The next day, Imani’s mother emailed the manager of the TIRH to ask for Imani to be admitted to hospital. The Court heard evidence that this was a ‘Nearest Relative request’ for hospital admission that should have been immediately forwarded to the local authority Approved Mental Health Professional (‘AMHP’) hub so that Imani could be assessed under the Mental Health Act 1983, but it was not. The Coroner found that this should have happened.
It transpired that Imani had not yet received the item on 12 June 2024 but received it the following day. Although RHTT practitioners knew of this information, they did not tell Imani’s parents who understandably thought the immediate crisis had passed.
The Coroner found that there were repeated missed opportunities by the mental health professionals who saw Imani between 13 June 2024 and the date of her discharge from the RHTT on 5 July 2024 to tell Imani’s parents that she had now received the item and that she intended to use it outside of the family home, where they lived together with Imani’s brother. Imani was seen on 11 occasions during this period and every practitioner she saw knew she had the item and that she had purchased it with the intention to take her own life.
Throughout this period, Imani told mental health professionals that she did not want them to share information with her parents about her care, which included not telling them about the item. The Coroner found that professionals should have appreciated that the only reason that Imani insisted on confidentiality was so that her parents could not stop her from carrying out her plan.
During the inquest, every RHTT practitioner who was called to give evidence said that they did not share information with Imani’s parents because they did not perceive there to be an ‘imminent’ risk to Imani’s life; an assertion which the Coroner found to be unsustainable.
During her summing up of the evidence, the Coroner detailed the number of times that Imani had told practitioners that she felt hopeless or intended to end her life, and the occasions on which practitioners simply listened as she told them that she had taken steps to distribute some of her possessions and was preparing to end her life. The Coroner found that steps could and should have been taken to safeguard Imani which possibly contributed to her death.
On 5 July 2024, Imani was discharged from RHTT during a visit with three professionals: her psychologist and care coordinator from the TIRH and a registered mental health nurse from the RHTT. Imani told them that she had used the item two days before to see what effect it would have on her and ‘blacked out’ until the following the day. This was recognised to have been a serious incident which resulted in the care coordinator questioning whether Imani should be discharged from the RHTT and asking whether Imani needed to be detained in hospital. Despite this, Imani was discharged with no effective option to maintain her safety over the weekend and in the knowledge that she would likely use the item again. The registered mental health nurse told the Court that, in her view, there was a 25-30% chance that Imani would take her own life before her next meeting with her care coordinator six days later.
The Coroner found that the professionals who visited Imani on 5 July 2024 should have escalated the serious incident before discharging her from the RHTT and that they ought to have taken immediate steps to safeguard Imani by breaching her confidentiality and telling her parents about her intentions. The Coroner found that Imani’s right to life had arguably been breached by the Trust and that these failings possibly contributed to Imani’s death.
The Coroner is currently considering whether to issue a report to prevent future deaths and a decision is expected by 15 October 2026.
Speaking after the inquest, Imani’s family said:
It was harrowing to hear mental health professionals describe my daughter as ‘calm’ and ‘capacitous’. If they had sought to consider her neurodiversity as well as her other mental health issues they would have seen a vulnerable adult in great distress, masking to avoid judgement. Following her death, I will work to ensure that mental health staff are more open knowledge sharing in cases of vulnerable adults with mental health challenges. Imani was abused during life; I hope what sits with her in death is the knowledge that she made a difference to so many young people in her role as a much-loved primary school teacher. We’re so grateful to our legal team for exposing the many failures of the Trust. Their willingness to listen and support us at every step of the way was a beacon of light in our darkest days.
Kelly Darlington, representing the family said:
Losing a child is an unimaginable tragedy for any parent and the findings in Imani’s inquest makes that grief even more painful for her family. The Coroner identified a significant missed opportunity to breach Imani’s confidentiality when professionals were told about her intentions to harm herself. This is a missed opportunity we see in so many cases where parents and carers are not properly involved and informed in their loved one’s care, at times when it matters the most.
Imani’s family are represented Kelly Darlington, Partner of Farleys Solicitors and Ciara Bartlam, Barrister of Garden Court North Chambers. They were also represented by Lily Lewis of Garden Court Chambers at an earlier stage of proceedings.
