Goodmayes mental health patient killed by train should not have been released, jury decides

PUBLISHED: 13:15 28 June 2017 | UPDATED: 14:50 28 June 2017

The inquest took place at Waltham Coroners Court.

The inquest took place at Waltham Coroners Court.


A Goodmayes mental health patient killed by a train a day after leaving hospital should not have been released, an inquest has concluded.

Christine Mary Smith, of Bushwood, Wanstead, took her own life at Stratford Underground Station at 7.03am on July 6 2016.

The 69-year-old grandmother - who had bipolar disorder and believed she was an MI5 agent - had consumed a significant amount of alcohol, had antipsychotic medication and anti-depressants in her system, and was carrying three packs of paracetamol.

Returning a unanimous conclusion of suicide at Waltham Coroners’ Court yesterday, the jury said North East London NHS Foundation Trust’s (NELFT) decision to grant Ms Smith seven days’ leave under a Section 17 order had contributed to her death.

They concluded: “The house was in an unsatisfactory condition and there should have been more of a progression with her leave.”

Sarah Deery, Ms Smith’s daughter who lives in Sweden, “had expressed shock at how quickly Mrs Smith was released from hospital”, the court heard.

There was a broken boiler and door awaiting repair although Ms Smith had been told that a carpenter would be fixing it the next day.

The house had already been professionally cleaned and Ms Smith had refused a live-in cleaner, according to her care community co-ordinator, Richard Kisembo.

Dr Babatunde Adeeko, who led the release at Goodmayes Hospital, in Barley Lane, Goodmayes, said Ms Smith had shown “no signs of resistance” about leaving and knew she could return to the ward at any point.

She was refused leave on May 23, after non-compliance with her anti-psychotic medication, but had been given mood-stabilising injections since.

Ms Smith denied having suicidal thoughts or thoughts of self-harm to NELFT’s Home Treatment Team (HTT) the day before her death.

Offering his condolences, A NELFT spokesman said the care plan was developed with Christine before her death and included preparing her home environment and 24-hour support while under the Section 17 leave.

He said: “In light of the efforts made to support Christine, her death was unexpected and all those involved in her care are very saddened by this tragic incident.”

You can call the Samaritans free from any phone on 116 123.

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