Hospital apologises to parents of woman, 35, who hanged herself

Hospital apologises to ‘heartbroken’ parents of privately-educated graphic designer, 35, who hanged herself after being let out of psychiatric unit for one night

• Caroline Forte was allowed to return home from hospital against family’s wishes
• For confidential support call the Samaritans on 116123 or go to samaritans.org

A hospital has apologised to the heartbroken parents of a woman who hanged herself when she was let out of a psychiatric unit for one night against her family’s wishes.

An inquest jury heard that Caroline Forte, 35, from Brighton, east Sussex, killed herself at her parents’ home after being allowed to leave a psychiatric unit in Eastbourne on weekend leave.

A coroner found lack of knowledge and poor communication by Amberley Ward at Eastbourne District Hospital (EDH) contributed to her death on February 20 last year.

In a statement issued by Sussex Partnership NHS Foundation, the trust apologised for its failings, and said: ‘We offer our sincere condolences to the family of Caroline Forte.

‘We apologise unreservedly for the failings in the care and support we provided Caroline and her family.

An inquest jury was told that Caroline Forte, 35, from Brighton hanged herself at her elderly parents’ home after she had been allowed to go home for a night

‘We will respond to the issues identified by the coroner and Caroline’s family as a priority.’

A five-day inquest, which concluded on March 14, found inadequate communication between hospital staff and with Caroline’s family contributed to her death.

A jury found there was no evidence of an overnight care plan or risk assessment prior to Caroline leaving the ward.

In a narrative conclusion, the jury found there had been a failure to follow leave of absence policy.

A statement provided by the family said: ‘As heartbreaking as it has been to relive it all again, this inquest has been very important for us as a family to get some answers.

‘Caroline was under section 2 of the Mental Health Act and as a family we trusted in the medical professionals and care system to keep her safe. They did not do that.’

Her sister Liz described Caroline (pictured) as ‘a happy, fun-loving person’

Darren Plant, matron at Amberley Ward, where Caroline had been detained, told the court on March 13: ‘Clearly, there has been a breakdown in communication.’

Caroline, who was privately educated at Brighton Girls School, was ‘hit hard’ when her relationship with her partner, Barry Wickens, broke down during lockdown in 2020.

The couple had bought and renovated their first home together but difficulties arose when they disagreed over having a baby. 

The inquest into Caroline’s death heard how she struggled with her mental health following the end of the relationship, before being admitted to a psychiatric ward.

Despite family insisting it was ‘unsafe’ for her to come home for an overnight stay, the hospital allowed her release and she was found dead shortly afterwards.

Penelope Schofield, the acting senior coroner for Brighton and Hove, told the inquest jury that ‘facts needed to be established’ around Caroline’s death and that the family had waited over a year for answers.

She said: ‘The family have indicated that they weren’t given any advice on how best to support Caroline.’

Attending the inquest were Caroline’s parents, Gillian and Anthony Forte, her older sisters, Liz and Sandra and her older brother, Chris.

In her witness statement, her sister Liz said: ‘We have lost a vibrant, clever, kind, loving and much-adored member of our family whose 35 years are certainly not defined by this relatively short illness.

‘Caro – as she was known to us – was a happy, fun-loving person, the baby of the family. She was an extremely talented and very successful graphic designer with an infectious giggle and strong family values.

‘She had been with her partner, Barry, for a few years and they had bought a house together which they did up.

‘It was a planned family home because Caro was very keen to start a family.

Caroline struggled with her mental health following the end of her relationship, before being admitted to a psychiatric ward in Eastbourne District General Hospital

‘Barry then decided he was unsure whether he wanted to try for a baby and so they had couples counselling.

‘However, the relationship continued to deteriorate and Barry eventually left in May 2020.’

Liz recalled how her sister had turned up at her house late one night, very upset.

‘Barry wanted shared custody of their dog, Doris, and there had been aggression and harassment with the police being involved,’ she told the jury.

READ MORE: Privately-educated graphic designer, 35, hanged herself when she was let out for one night from psychiatric unit after splitting with partner who didn’t want a baby and fighting custody battle over their dog

‘She asked if she could come and stay with me because she ‘didn’t feel right’.’

The coroner heard how Caroline began to show signs of psychosis in November 2021, believing that her phone had been tapped and she was becoming paranoid about her devices.

The family sought medical help and Caroline’s condition stabilised enough for her to go on a planned holiday to Costa Rica over Christmas. 

However, on her return in January 2022, things took a turn for the worse, the jury was told. 

The sister’s statement continued: ‘She wasn’t okay. She kept asking for help in changing passwords on all her accounts and she talked continuously about being hacked.’

The family agreed that Caroline should stay in Leeds with her other sister, Sandra, who was on maternity leave and who would therefore be able to look after her and keep her company.

The coroner heard that while in Leeds Caroline attempted, twice, to kill herself with an overdose.

She received emergency psychiatric care under the Leeds and Yorkshire NHS Partnership Trust and was then transferred back down to Sussex where she was admitted under the Mental Health Act to the psychiatric ward of Eastbourne District General Hospital.

She hanged herself less than a month later.

The jury returned a narrative conclusion of suicide, and mentioned her provisional diagnosis of severe depression with psychotic symptoms.

Coroner Penelope Schofield said she would be carrying out three prevention of future deaths reports.

‘The lack of knowledge of the policies is clear from the evidence,’ the coroner said.

One of the reports will be to Sussex Partnership NHS Foundation Trust regarding ‘clear findings around failure to adhere to policies’.

For help and support, contact the Samaritans for free, anonymously, on 116 123 

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