A woman was tragically found dead just days after leaving for hospital after attempting to take her own life, an inquest has found.
Fizza Tazeen Ahmed was found dead on April 3, 2022, in woodland in south Manchester. The 39-year-old left Wythenshawe Hospital on March 29, having spent 10 days in its Bronte Ward based at Laureate House. The Bronte Ward, a mixed gender acute ward for patients with mental health problems, is run by Greater Manchester Mental Health Trust.
Ms Ahmed was there as an ‘informal’ — i.e. voluntary — patient following a suicide attempt on March 19. She had called an ambulance for herself and then agreed to transfer from A&E to the mental health unit, area coroner Zak Golombek heard today (April 5, 2023).
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During the hearing, he ruled that Greater Manchester Mental Health Trust (GMMH) made ‘shortcomings in care’ with Fizza, but added those did not lead to her death directly. That was despite an internal review by GMMH itself suggesting the shortcomings did ‘on the balance of probabilities’ lead to her death.
The review was carried out by Dr Sean Lennon, who focused on the decision to discharge Fizza — at her request — on March 29 to the home based treatment team. Consultant Dr Shahid Hussain approved the discharge, and instructed Lucy Ralphs to carry out an assessment with Fizza looking into the level of risk she presented to herself.
Ms Ralphs found that Fizza was low risk, due to not presenting any thoughts of self-harm, suicide, or absconsion while in hospital.
“I think the point we would make was that in the multidisciplinary team (MDT) meeting there was an acceptance that Fizza would be discharged and [it would be] a supported discharge,” Dr Lennon told courtroom 1 of Manchester City Coroners Court.
“I think that could have been more effective if the home based treatment team had directly spoken to Dr Hussain or been involved in the discussion in the MDT so it was clear what was expected. When we looked at the records we could not see Dr Hussain understood what would happen — that it would not be taken on by the home based treatment team, but have a three day and seven day review.
“The process may not have been the same if Dr Hussain and Lucy Ralphs had a discussion, and Dr Hussain could have said ‘we need to see her tomorrow and not leave it three days’.
However, Dr Lennon added he ‘accepted’ a statement from Lucy Ralphs which said that patients ‘could have engaged in much more intrusive support’ if it was flagged as a concern during the preliminary meeting or the two follow-ups. Under questioning from John Sharples, representing GMMH, he also accepted Fizza was not ‘detainable’ — i.e. able to be held in hospital against her will — on March 29, when she was discharged.
Following Fizza’s discharge, Ms Ralphs conducted the initial assessment, where she decided follow-up appointments would be sufficient to manage the risk posed. Ms Ralphs then telephoned Fizza on March 31 to arrange the first appointment.
However, Fizza was coughing on the phone, and a Covid-19 test she took on leaving hospital came back with a positive result on the same day. The pair agreed to meet the following day, April 1, with Ms Ralphs wearing full PPE — as per NHS policy at the time.
Tragically, Fizza went missing at 5:15pm on the afternoon of March 31. Her body was found in woodland on April 3.
Coroner Zak Golombek ruled that her death was suicide, with a medical cause of death listed as 1A hanging. In a lengthy conclusion, he told the court: “Very sadly, Fizza was reported as missing later on March 31 and her body was discovered a few days later on April 3 woodland [in south Manchester].
“Returning to Dr Lennon’s evidence with findings of the review and causation, I find accordingly. Based on my analysis of that evidence — that the opinion set out in the report [said] on the balance of probabilities Fizza would not have taken the actions that led to her death, but for the shortcomings of care — I do not accept that evidence. I cannot find it withstands logical analysis, particularly considering Dr Hussain and Lucy Ralphs. I do accept there was no formal risk assessment, but there were risk assessments at MDT reviews, particularly on March 29.
“There is insufficient evidence to find, on the balance of probabilities, that had those shortcomings not occurred Fizza would not have taken the actions and therefore not have died.
“Where there is insufficient evidence, it’s not probable [shortcoming in care led to her death]. At its height there would be a possibility but there are too many impenetrables when one analyses the entirety of the evidence.
“I am satisfied she intended to take her own life. I must return a short form conclusion of suicide.”
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