Sally Mays, 22, who had long-standing mental health issues, died at home in Hull on July 25 2014 after she was turned away by the Humber NHS Foundation Trust crisis team earlier that day.
Despite being thought to be at “real risk of suicide” and “extremely vulnerable”, staff failed to admit her to an inpatient psychiatric bed, the High Court in London was told.
Her parents, Andy and Angela Mays, from Hull, have spent six years battling for a “full and fearless” investigation into her death, arguing that all the circumstances of the day she died were not revealed at an October 2015 inquest.
On Wednesday, High Court judges quashed the original inquest and ordered a new one to be held so that fresh evidence could be investigated.
Speaking after the ruling, Mrs Mays told the PA news agency: “Sally had her whole life in front of her. She was a beautiful and intelligent girl who sadly struggled with mental health issues.
“Sally always said to the professionals responsible for her care: ‘If anything happens to me you’ll have my mother to deal with.’ She was right. She deserved so much better.”
Professor Paul Marks, senior coroner for East Riding of Yorkshire and Kingston upon Hull, previously concluded that the decision not to admit Ms Mays constituted “neglect” which bore “a direct causal relationship to her death later that evening”.
He said she was “inappropriately assessed” and not treated with appropriate “respect or dignity”, adding that if she had been admitted following an initial assessment or further “missed opportunities” she “would have survived and not died when she did”.
A further missed opportunity to save her life came from a 69-minute delay to an ambulance arriving after Ms Mays’s call was not categorised appropriately, the coroner said.
He concluded that Ms Mays’ actions, which included an overdose, “undoubtedly caused her death” but “her intentions remain unknown”.
Bridget Dolan QC, representing her parents, told the High Court in written submissions that following the inquest it was revealed that a conversation between one of their daughter’s care coordinators and a consultant psychiatrist on the day she died was “knowingly withheld” from the inquest.
Laura Elliot, who had brought Ms Mays to hospital on July 25, was leaving the unit that had refused admission when she spoke to Dr Kwame Fofie in the car park.
Ms Dolan claimed that in one account of their exchange “Dr Fofie reassured her that ‘everything would be alright, and Sally would settle down or be picked up by a service”.
She said that after Ms Elliot had discussions with two consultant psychiatrists, details of this conversation were not revealed to an internal NHS trust investigation nor the senior coroner.
Ms Dolan said Ms Elliot’s and Dr Fofie’s accounts of the conversation had changed over time, but argued it allegedly revealed there was “a clear opportunity” for a consultant psychiatrist to “intervene and reverse” what the coroner had called an “illogical, quixotic and unconscionable” decision not to admit Ms Mays.
No investigations surrounding Ms Mays’s death so far had “sought to establish the facts of what actually happened in the car park that day”, Ms Dolan said.
She said the Crown Prosecution Service (CPS) had decided not to prosecute any NHS staff for perverting the course of justice, and a 2015 NHS trust-commissioned independent review on Ms Mays’s care was not told of the conversation.
A draft report from a second internal investigation has not been finalised, and no outcome made public, Ms Dolan said.
She added that Ms Elliot was referred to the Nursing and Midwifery Council (NMC) for investigation after the inquest and it found she had no case to answer.
A General Medical Council (GMC) investigation of Dr Fofie concluded with no further action being taken.
Ms Dolan claimed there was a “real possibility” that the senior coroner’s narrative conclusion would have been “differently framed” if the withheld material had been available and examined.
“As the consultant psychiatrist to the admissions unit Dr Fofie could have stepped in and reversed the unconscionable gatekeeping decision and averted Sally’s death,” she alleged.
Ms Dolan said the information was “not trivial or irrelevant to her death”, but “sufficiently serious and significant enough” to lead to the investigations.
Lady Justice Simler, sitting with Mrs Justice May and Judge Thomas Teague QC – the chief coroner for England and Wales – said that it was “necessary and desirable in the interests of justice” to quash the inquest and order a fresh one.
In her ruling, the judge concluded that “fresh” and “relevant” evidence was now available and that a new inquest was “likely to lead to additional findings of fact being made”.
She said it was “clear” from documents that a “conscious” decision was taken “both before and during the inquest to withhold information about the car park conversation”.
The judge concluded that a new inquest was needed “for the new evidence concerning the conversation in the car park to be investigated and for the facts in relation to that to be established”.
Mrs Mays, speaking afterwards outside the Royal Courts of Justice, said she was “relieved” by the ruling.
“All we’ve ever wanted is a full and fearless investigation into the facts of what happened to Sally in her final hours. This has yet to be achieved,” she said.
“Families should not have to fight over such a prolonged period to get the most basic details of a death of a loved one.”