Before HM Assistant Coroner Mr J Puzey

Worcestershire Coroner’s Court, Martins Way, Stourport-on-Severn, DY13 8UN.

Scheduled 28 June at 1pm to Wednesday 3 July 2024

Beth Taylor Jarvis was a much-loved daughter, sister and aunt. She was born on 4 July 1997 in Hammersmith, London and died on 25 March 2023 aged 25 years old. She was under the care of Herefordshire and Worcestershire Health and Care NHS Trust at the time of her death. An inquest will now examine the circumstances.

Beth had a complex history of mental ill health, self-harm and suicide attempts. She suffered a number of significant traumas including being a victim of sexual assaults and domestic violence on more than one occasion. She frequently self-harmed and was admitted to acute mental health wards in both Worcestershire and West London on a number of occasions throughout her life.

On 16 March 2023 Beth was admitted to Hill Crest ward on a voluntary basis after her suicidal ideation had significantly increased with her making significant attempts on her life on a number of occasions within a short space of time in March 2023. She was assessed as being high risk at that time.

On 22 March only 6 days after being admitted Beth was discharged back into the community. Due to reasons around her risk to her family being raised prior to her admission she was not able to be discharged back to her family’s address and instead was discharged into a temporary Bed and Breakfast accommodation despite the fact that for much of her life she had either lived with family or in supported accommodation.

Two days later on the evening of 24 March Beth took a significant overdose and was taken to the Accident and Emergency Department. Her family were told that she would be assessed by the mental health team but that she would be kept in over night and likely assessed in the morning. Instead Beth was assessed and discharged at 2am on the morning of 25 March. Although staff tried to contact her family due to the time of discharge they were not able to get hold of them.

Beth was therefore discharged alone back to the temporary Bed and Breakfast. Beth was sadly found deceased the next day having sent her mother a text message to say that she was going to end her life.

The inquest will seek to explore the following issues:

1) Her mental health care and treatment by Herefordshire and Worcestershire Health and Care NHS Trust from January 2023 until her death

2) The appropriateness of her discharge from Hill Crest on 22 March 2023;

3) The appropriateness and suitability of her discharge into temporary Bed and Breakfast accommodation on 22 March 2023;

4) The appropriateness of the discharge from the Emergency Department on 25 March 2023.

The family is represented by Gemma Vine of Ison Harrison and Ciara Bartlam of Garden Court North Chambers. Other Interested persons represented are Herefordshire and Worcestershire Health and Care NHS Trust.

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