THE BEREAVED family of a Reading woman who was found dead in her home less than 24 hours after being released from hospital, has said they feel "badly let down by mental health services".

Sarah Adams, 64, was admitted to Cygnet Harrow Hospital as a psychiatric inpatient after attempting to take her own life on April 4, 2022.

This was due to her feeling "overwhelmed" and "not knowing what was happening with her health".

Despite being diagnosed as a paranoid schizophrenic, Sarah was eventually sent home without a care plan in place and with a large amount of medication.

Berkshire’s Coroner’s Court heard that the hospital arranged for her to receive twice-daily visits from the Crisis Team following her discharge to assess her mental health.

However, upon investigation, the coroner found that this information was not relayed to the Crisis Team in Reading as a result of a 'misunderstanding' on the day Sarah was discharged.

During the inquest at Berkshire Coroner's Court this month, assistant Coroner Alison McCormick heard that on the evening of May 18, Sarah told one of her neighbours that she 'had been sent home with a load of tablets and didn’t know what she had to take'. She also reportedly told the neighbour that the hospital had told her that a nurse would come to see her at home but this had not happened. 

Sarah was tragically found dead at her home in Reading on May 19, 2022, less than 24 hours after she was discharged.

Sarah’s niece, Izzy Adams, who had a big role in caring for Sarah and liaising with professionals about her care and treatment said that she felt let down by both Cygnet Hospital and the Berkshire Healthcare NHS Foundation Trust (BHFT).

Izzy said: “I did all that I could to care for Sarah and to get her the support she needed. I feel strongly that I was not listened to by professionals and that they failed Sarah. 

“I still do not understand how Sarah could be discharged from hospital without the support she needed and with a large supply of medication when she had tried to take her own life just a few weeks earlier.

“lt was clear that Sarah was not able to understand or manage her medication and I feel strongly that Sarah should never been left in charge of it.”

A narrative conclusion was read out at the inquest in Reading Town Hall recognising that issues relating to Sarah’s discharge from Cygnet Harrow Hospital and the support provided to her after she returned home probably contributed to her death.

Following the four-day inquest, where the court heard from a variety of experts, it was ruled that there had been an arguable breach of Sarah’s ‘right to life’ under Article 2 of European Convention on Human Rights, on the basis that Cygnet and BHFT had assumed responsibility for Sarah’s care. 

Assistant Coroner Alison McCormick said that other failings by BHFT before Sarah’s hospital admission also possibly contributed to her death.

A Prevention of Future Deaths report will be issued by Ms McCormick to Cygnet Harrow, to BHFT and to Reading Borough Council (RBC). 

Izzy expressed her gratitude to the coroner for her detailed investigation of what happened to Sarah and for recognising that there were significant failures that led to her death.

A spokesperson from Berkshire Healthcare NHS Foundation Trust said: "We would like to extend our sincere condolences to Sarah's family and friends, following her sad death.

"We recognise that we could have done things better, and have taken learning from this tragic case to put improved processes in place."