Hayley Beavington

I am:   Coroner ME Hassell Senior Coroner Inner North London St Pancras Coroner’s Court Camley Street London  N1C 4PP

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.

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.

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.

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