Alix Knowles

I am Emma Serrano, Acting Senior Coroner, for the coroner area of the Staffordshire.

On the 10 January 2024 2017, I commenced an investigation into the death of Miss Alix Elizabeth Knowles.  The investigation concluded at the end of the inquest on 2 October 2024. The conclusion of the inquest was a short form conclusion of:  Suicide The cause of death was: 1a Multiple Traumatic Injuries 1b Fall

i). Miss Knowles was 30 years of age, with in life diagnosis of Emotionally Unstable Personality Disorder and Bi-Polar effective disorder. ii). She had previously expressed suicidal thought and attempted to take her own life. iii). On the 8 December 2023 she attended the Queens Hospital, Burton Upon Trent, Accident and Emergency department via ambulance. Information given to the department by paramedics was that she had attempted to cut her throat and was threatening to commit suicide. iv). On the 8 December 2023 she was seen by the Mental Health Liaison team, to consider  detention under the Mental Health Act. The mental health liaison team were not aware of the reasons for her attendance to A&E, because  bank  staff  are  not  allowed  access  to  the  electronic  computer system.  The mental health liaison team made the decision that she would not be detained under the mental health act, and she was discharged home. v). It was heard in evidence that Hospital Trusts cannot access other hospital trusts patient notes, because of the use of different computer systems. vi). In the early hours of the 9 December 2023, Alix Elizabeth Knowles made her way to the bridge above the [REDACTED], where she jumped onto the road below and was hit by two motor vehicles.

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. –

1. Bank Staff are not able to access patient notes before assessments;
2. Different NHS Trusts are unable to access patient notes, because the computer systems used do not allow this.

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.