Coroner raises concerns as inquest into woman’s death concludes after almost four years

At the end of the inquest into Chloe Louise Barber’s death, Professor Paul Marks, the senior coroner for Hull and East Riding, concluded that “there is a risk that future deaths will occur unless action is taken”.

According to a report made by Professor Marks, Ms Barber was found dead at her home in November 2021. The death was ruled a suicide.

Professor Marks’ report explained Ms Barber had a history of self-harm and of taking multiple overdose of tablets. The report added she had been detained under various sections of the Mental Health Act 1983 – her last admission was to the Cygnet facility in Sheffield.

The report said: “Whilst an inpatient, she showed improvement in various aspects of her mental health, probably due to the administration of the atypical antipsychotic drug, aripiprazole.

“She was at a point in her life where she was making a transition between children’s and adolescent mental health services and adult services. She was adamant in her refusal to engage with adult mental health services.”

Professor Marks found that there had been valid concern about the lack of documentation and poor communication between services and partner organisations.

The coroner noted that the issue of cessation of aripiprazole therapy may have more than minimally, trivially or negligibly resulted in increased emotional instability leading to impulsive behaviour, but this was one of a number of issues which may have contributed to her death on November 3, 2021.

In the report, Professor Marks added: “The unpredictability of impulsive behaviour associated with evolving emotionally unstable personality disorder, coupled with Chloe’s lack of engagement with provided services or services that may have been offered, makes it probable that there was no realistic opportunity to prevent her death.”

The coroner concluded that there are a number of matters of concerns in relation to Ms Barber’s death:

• Evidence was heard that there is a nationwide concern that there is no clearly defined pathway that assists young persons making the transition between Childhood and Adolescent Mental Health Service (CAMHS) and adult psychiatric services, to ensure a smooth transit and continuity of care.
• Concern was raised that there are no clear guidelines about where and by whom depot preparations of antipsychotic may be administered.
• There was “considerable uncertainty and ignorance” about the provision of aftercare between some healthcare workers and social workers.

The coroner has sent his report, among others including Ms Barbers’ parents, to Humber Mental Health NHS Trust, Cygnet Health Care, NHS England, Royal College of Psychiatrists, Minister of State, Department of Health and Social Care.

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