Inquest into the death of Emma Jane Claridge

19y · Female·neck compression due to hanging

Emma Jane Claridge, 19, died by hanging at her home on 26 September 2009, nine hours after being granted day leave from the Cowdy Ward psychiatric ward where she was a voluntary patient. She had been admitted following acute suicidal ideation and received a diagnosis of hebephrenic schizophrenia. Although she expressed suicidal thoughts on 25 September, overnight leave was appropriately refused. On 26 September, after a review where she denied suicidal thoughts and could not formulate a safety plan, she was granted only day leave. The clinical team believed this was safe given her improvement and voluntary status. However, critically, there was lack of clarity about the scope and duration of leave between medical staff and family. The deceased was found with day leave materials and later took her own life. While clinical decision-making was defensible given fluctuating mental state and her previous successful leave experiences, system failures included inadequate handover communication, delayed escalation of her absence (5+ hours), and insufficient on-call mental health team involvement in the response.