在 6 日 2011 the jury returned a decisive and highly critical verdict of the acts and omissions of Norfolk and Waveney Mental Health NHS Foundation Trust following the inquest into the circumstances of the death of Louise Noon. The jury’s verdict came after several hours of careful deliberation and three days of detailed evidence and legal submissions before HM Coroner for Norfolk, William J Armstrong sitting at Norwich City Football Club grounds.
Louise died by suicide in her room at Northgate Hospital on 23 七月 2011 having quickly become very ill suffering from symptoms of bi-polar affective disorder. Louise hanged herself using a cord in her possession from a ligature point within her room, despite having made several similar suicide attempts in the days preceding, of which she alerted staff.
The jury concluded that there had been a catalogue of systemic and individual failings by the Trust in the immediate lead up to Louise’s death, particularly serious failures by the care team to communicate Louise’s risk of self harm; serious failures to properly risk assess and put in place an adequate care plan; and a failure to properly search Louise’s possessions for potential ligatures.
Inquest told that Caister woman’s death by hanging could have been prevented