Woman, 18, took own life, coroner concludes

A young woman with a history of self harm and stays in psychiatric hospitals took her own life, a coroner has concluded.

Chloe Barber, 18, from Driffield, was found dead at home by a family member on 3 November 2021.

Hull coroner Prof Paul Marks said it was "probable there was no realistic opportunity to prevent her death".

Despite this, he said his inquiries found there was not a "clear path" for patients to transition from child and adolescent to adult mental health services, and is now compiling a Prevention of Future Deaths report to highlight the issue.

Following the inquest into Miss Barber's death, Prof Marks described the family's experience as "very harrowing".

He said that he believed "nationwide there is not a clear path for transition from Child and Adolescent Mental Health Services (CAMHS) and adult psychiatric services".

Miss Barber had first attempted to self-harm in 2017 when she was in Year 9 and experienced bullying at school, the inquest heard.

Following this incident, she had contact with CAMHS. A further attempt at self harm was made in 2018.

Miss Barber went on to have several stays in psychiatric units, including in Hull, before being transferred to Cygnet Hospital in Sheffield in 2021 after being sectioned under the Mental Health Act.

She came home after she managed to successfully appeal detention via a mental health tribunal and no major incidents initially occurred, the inquest heard.

On 3 November 2021, Miss Barber was found unconscious at her home.

A family member tried to resuscitate her and called 999 but Miss Barber was declared dead by paramedics a short time later.

Prof Marks said Miss Barber had an "evolvingly unstable personality disorder" which was characterised by "difficulties on how an individual feels about themselves and is associated with impulsive behaviour".

He added that Miss Barber, on the balance of probabilities, "did have capacity in refusing to engage with adult psychiatric services".

Concerns were raised about Miss Barber's aftercare, care programme approach, capacity assessment and risk management processes around vulnerable adults.

However, Prof Marks said while "many matters were true or partially true, no causation flows from them".

"The unpredictably of impulsive behaviour with evolving emotional personality disorder coupled with services offered makes it probable there was no realistic opportunity to prevent her death," he concluded.

After the hearing, Chloe's family said in a statement issued through Hudgell Solicitors: "It's difficult to put into words the kind of person Chloe was. She was amazing, bright, brilliant, beautiful, caring and stubborn. A truly wonderful young lady.

"She loved all kinds of music and was always wearing headphones. She was always dancing around wherever she was to the song Pocketful of Sunshine.

"She was a gifted artist and loved drawing, and we always proudly displayed her artwork on the walls of our family home. She loved to shop, spending all her money in Primark and loved animals, especially her pets and her dog, Chester."

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