Finding into death of Ms NXA

54y · Female·neck compression secondary to hanging

Ms NXA, a 54-year-old woman with complex mental health conditions including depression, CPTSD, and anxiety, presented to hospital after a suicide attempt by overdose on 9 August 2021. She was experiencing severe tinnitus-related distress alongside multiple psychosocial stressors. Despite expressing clear suicidal ideation and a specific plan to end her life upon discharge, she was discharged on 10 August 2021 with minimal safety planning, no mental health treatment arranged, and without a local GP. The clinicians adopted a narrow formulation attributing her suicidality solely to tinnitus and deemed psychiatric admission unnecessary. She died by hanging the following day. The coroner found multiple missed opportunities: inadequate holistic risk assessment, failure to recognise the expressed suicide plan as a new change requiring escalation, lack of investigation into her tinnitus, and extremely poor discharge planning that was disproportionate to her demonstrated risk.