Hayley Beavington: Prevention of Future Deaths Report
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Date of report: 20/02/2025
Ref: 2025-0097
Deceased name: Hayley Beavington
Coroners name: Edwin Buckett
Coroners Area: Inner North London
Category: Suicide (from 2015) | Mental Health related deaths | Hospital Death (Clinical Procedures and medical management) related deaths
This report is being sent to: North London NHS Foundation Trust
| THIS REPORT IS BEING SENT TO: 1. Chief Executive Officer North London NHS Foundation Trust St Pancras Hospital 4 St Pancras Way London NW1 0PE | |
| 1 | CORONER I am: Coroner ME Hassell Senior Coroner Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP |
| 2 | CORONER’S LEGAL POWERS I make this report under the Coroners and Justice Act 2009, paragraph 7, Schedule 5, and The Coroners (Investigations) Regulations 2013, regulations 28 and 29. |
| 3 | INVESTIGATION and INQUEST On 23 September 2024, one of my assistant coroners, Edwin Buckett, commenced an investigation into the death of Hayley Beavington, aged 50 years. The investigation concluded at the end of the inquest on 10 February 2025. I made a determination at inquest of death by suicide. |
| 4 | CIRCUMSTANCES OF THE DEATH Slightly before 1am on Saturday, 21 September 2024, Ms Beavington jumped from the fifth floor balcony of her home. She had paranoid schizophrenia and long term substance misuse disorder. Following admission to hospital for [REDACTED] toxicity earlier in September, when she was under the mental health care of North London NHS Trust, she was discharged home the day before she died. |
| 5 | CORONER’S CONCERNS During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths will occur unless action is taken. In the circumstances, it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. When planning for Ms Beavington’s discharge from hospital, it was agreed that the best place for her to go was a local crisis house. Upon application, the foundation year 1 doctor (FY1) was told by the crisis house team that this was not possible because: – Ms Beavington had secure accommodation; and – she was no longer actively suicidal. This was despite the fact that: – there was a strong suspicion that Ms Beavington was the victim – of cuckooing in her own home; and the team view was that she was definitely at risk of suicide. The consultant psychiatrist in charge of Ms Beavington’s care did not give the FY1 any instruction as to how to challenge the decision that the consultant believed was wrong. Instead, the consultant instructed the FY1 to leave it for three days and then just try again in the same way. By this time, Ms Beavington decided that she had waited too long and did not want another attempt to be made. Ms Beavington was discharged home and killed herself at 1am the next morning. |
| 6 | ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and I believe that you have the power to take such action. |
| 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 22 April 2025. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. |
| 8 | COPIES and PUBLICATION I have sent a copy of my report to the following. – the mother of Hayley Beavington – the daughter of Hayley Beavington – Care Quality Commission for England – NHS England – HHJ Alexia Durran, the Chief Coroner of England & Wales I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response. |
| 9 | DATE SIGNED BY SENIOR CORONER 20.02.25 ME Hassell |