Finding into death of Yvonne Rose Vizard

72y · Female·Obstruction of the airways of the neck

A 72-year-old woman with moderate-severe expressive and receptive dysphasia following an acute left middle cerebral artery stroke died by hanging three months post-discharge from rehabilitation. Critical deficiencies were identified in post-stroke mental health care: there was no routine screening for mood disorders using validated tools during rehabilitation or in community follow-up, despite clinical guidelines recommending this. Families received no education about the 33% risk of depression in stroke survivors generally, or the 60% risk in those with aphasia specifically, and were not informed of the doubled suicide risk in the first two years post-stroke. The patient had expressed wishes to be dead, but these were not escalated for psychological assessment. Personality changes post-stroke were neither documented nor discussed with family. Earlier identification of mood disturbance through screening and family education about depression recognition could potentially have enabled earlier intervention.