Jury finds the failure by West London NHS Trust to follow due procedure probably contributed to Deborah Hayes’ death
Deborah, a much-loved sister, daughter, aunt, and friend, was unfortunately found deceased at her home on 23 December 2023, having acted by her own means to end her life.
A five-day inquest into the death of Deborah Hayes concluded on 27 June 2025. Deborah died at her own home following ingestion of a toxic substance. The jury concluded that Deborah died by suicide and found that the West London NHS Trust’s attribution of risk and failure to follow due procedure when carrying out a telephone assessment on 21 December 2023 probably contributed to her death.
Deborah’s family spoke at the inquest about her close connection with her mother, her baking and cooking, her capabilities at DIY and her love for sewing and mountain biking.
Over the course of the inquest, the jury heard evidence that four police officers and two paramedics had attended on Deborah on 21 December 2023 following a call to emergency services from a concerned friend that Deborah had ingested a potentially fatal substance. Deborah had told police officers that she had taken this substance and told paramedics she had a fixed plan to end her life. Paramedics from the London Ambulance Service had called the West London NHS Trust Single Point of Access (‘SPA’) line on 21 December 2023. A call handler from SPA had spoken with Deborah and a Senior Clinician had assessed Deborah’s risk as being non-urgent. A referral to Mental Health services had been made with no timeline for contact with Deborah. The jury heard evidence that other urgent referral options were available, with response times of 4 to 24 hours for a face-to-face assessment.
The jury also heard evidence that Deborah had diagnoses of Emotionally Unstable Personality Disorder, Agoraphobia and Body Dysmorphic Disorder. She had been known to West London NHS Trust since August 1994 and had last been discharged from their services in October 2023. She had attempted suicide on multiple previous occasions by similar methods.
Following a five-day inquest – where detailed evidence was heard from various witnesses, including Deborah’s family and friends, the Metropolitan Police Service, the London Ambulance Service and the West London NHS Trust – the jury returned a conclusion that ‘the attribution of the category of risk [by West London NHS Trust] probably more than minimally contributed to [Deborah’s] death. This is due to the failure to follow due procedure when carrying out the assessment’.
The Coroner was HM Assistant Coroner for West London Coroner’s Court, Dr Anton van Dellen. The Coroner ruled at the conclusion of the evidence that Article 2 ECHR was engaged as there was an arguable systemic breach due to the arguable failure by West London NHS Trust’s SPA service to provide an effective system for assessing an individual’s mental capacity at the time of Deborah’s death, which he considered to be a serious regulatory failure.
The Coroner declined to make a Prevention of Future Death report on the basis that he had heard sufficient evidence that there was now a system for assessing capacity within the Trust. He ruled that he was ‘reassured that if another patient such as Deborah contacted SPA today such a call would be managed in a very different way and that is in [his] view in no small part from the learning from Deborah’s death. Deborah’s death has enabled the system to become a lot safer and hopefully prevent other families having the grief and loss experienced by Deborah’s family’.
The family were represented by Rachel Woodward instructed by Basmah Sahib of Bindmans Solicitors.
The other Interested Persons were the Metropolitan Police Service, the London Ambulance Service and the West London NHS Trust.
For further enquiries about Rachel, please contact Senior Practice Manager Melvin Warner.
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