The inquest into the death of Hilary Jane Chapman has concluded, on 4th February 2026, identifying deeply troubling findings about failures in communication and care during her detention under the Mental Health Act at Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV), Lanchester Road Hospital.

Hilary was remembered by those who knew her as thoughtful, generous, principled and deeply caring, with a warmth and humour that touched everyone around her. Her intelligence, compassion and quiet strength made her not only loved within her family but widely respected in her community.

Hilary died on 11 March 2025 at St Cuthbert’s Hospice, Durham, after suffering a hypoxic brain injury following cardiac arrest. Evidence heard at inquest established that, on the balance of probabilities, Hilary had taken her own life while on section 17 leave from Tunstall Ward at Lanchester Road Hospital between 22 and 24 February 2025.

The jury identified serious systemic failings. These included inadequate communication between professionals and Hilary’s family about the granting and conditions of her section 17 leave, failures to follow leave-contact requirements, and incomplete risk assessment prior to overnight leave.

A family deeply involved in Hilary’s care

Throughout Hilary’s illness, her family, particularly her sister Rachel, remained closely involved, raising concerns, attending meetings and supporting her recovery.

The inquest heard that Hilary’s sister attended the multidisciplinary meeting where unescorted leave was discussed. However, the Trust accepted that the records did not specify when overnight leave would begin and that Hilary’s sister was not informed that Hilary would be granted unescorted leave that day and would be on overnight leave that weekend.

Staff proceeded on the assumption that Hilary herself would share this information, despite the family’s active involvement in her care.

For Rachel and the wider family, this lack of communication proved devastating. Had they known the precise terms of Hilary’s leave, they believe they could have provided additional protection and support.

Rachel has since said that if meaningful changes had been made earlier, she believes her sister would still be alive.

Missed opportunities while Hilary was on leave

Evidence also showed uncertainty and inconsistency in how staff monitored Hilary during her unescorted leave.

Although attempts were made to contact her by telephone on 22nd; 23rd and 24th February, Hilary did not answer her phone or return calls. The Trust later accepted there was no clear contingency plan for what should happen if she did not respond, and no documented escalation despite repeated unanswered calls. The Trust did not contact family or re-assess Hilary’s risk.

Hilary was found in her car which was parked in the hospital grounds. CCTV footage confirmed that the vehicle had been there since 22 February 2025.

By the time Hilary failed to return to the hospital on 24 February 2025, opportunities to intervene had already been lost, and she sadly died on 11th March 2025.

Earlier warning signs: a Prevention of Future Deaths report

Perhaps most concerning is that Hilary’s death occurred just months after the same coroner issued a Prevention of Future Deaths (PFD) report in August 2024 following another mental health death involving section 17 leave.

In that earlier case, the coroner warned that:

  • Families were not informed of section 17 leave conditions
  • Carers were not provided with leave documentation
  • Compliance with communication requirements was inconsistent and below expected standards

These failings created a risk of future deaths unless action was taken.

Despite the Trust outlining policy reviews, audits and training in response, Hilary’s case suggests that practice and culture had not changed in time.

Changes only after Hilary’s death

Following Hilary’s death, the Trust stated they have introduced new processes, including:

  • A formal leave discussion form to record contingency planning and family involvement
  • Clearer documentation of MDT decisions and escalation planning
  • Improved auditing and monitoring of section 17 leave compliance

These measures were implemented as learning from Hilary’s case.

However, when addressing the coroner about failures to communicate leave conditions, the Trust relied on changes to forms rather than policy, which the coroner did not accept as sufficient. A further Prevention of Future Deaths report is now expected.

A call for transparency and family involvement

Rachel is now calling for national change so that families:

  • Receive clear written information at the start of detention
  • Are told exactly what leave is granted and on what conditions
  • Are given copies of section 17 leave documentation automatically (both hard copies and electronically if possible)

If she had known that this paperwork existed, she would have asked for the leave prescription herself rather than relying on the Trust’s communication.

Supporting families after mental health deaths

Hilary’s death highlights the critical importance of:

  • Open communication with families
  • Robust risk assessment before leave
  • Learning from previous deaths without delay

For families navigating the aftermath of a mental health death, the inquest process can be overwhelming. Specialist legal support can help ensure answers are obtained and lessons are learned.

If you have concerns about the care a loved one received while detained under the Mental Health Act, our inquest and clinical negligence team is here to help.

Hilary’s family were represented at the inquest by Sarah Magson of Ison Harrison and Counsel Sophie Watson of Parklane Plowden Chambers.

On 11th December 2025 the Government announced a Statutory Public Inquiry into Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV). Further information about the Inquiry, and our work representing more than 100 individuals affected by failings and substandard care at the Trust, can be found here: TEWV Inquiry – Do You Have Concerns Over Patient Safety?