Death of Derbyshire woman, 27, with ‘long history of mental health issues’, could not have been averted

Jessica Morley, 27, was found dead at her home address – 43 Damstead Park Avenue, Alfreton – on January 25 2022.

During an inquest held today (Tuesday, July 19) at Chesterfield Coroner’s Court, Assistant Coroner Susan Evans read a statement on behalf of Jessica’s mother – in which she said that her daughter had suffered with mental health problems for many years. She was receiving care from mental health staff, and her mother felt she was engaging well with them – but she added that “nothing was able to improve her condition to the point where she could live a normal life.”

Three days before her death, Jessica had travelled to Chesterfield with a close friend. The coroner read his statement to the court, in which he said she did not mention any suicidal thoughts on this occasion – although she seemed “a bit stressed” about her washing machine having broken.

That evening, Jessica read a news article about an inquest covering another friend’s suicide which “upset” and “shook her up”.

Three days later, this friend received a call from Jessica’s social worker, who was concerned for her welfare. She had not been able to contact Jessica to confirm their next visit, and asked him to check on her – when he arrived at Jessica’s address, he discovered that she had passed away.

Jessica’s social worker, employed by Derbyshire County Council, said that Jessica had begun to struggle in January 2022, and had expressed suicidal thoughts to her and a colleague. The court heard that Jessica said she had the means to go through with it, and had set a date to do so – although this was not the date on which she died.

This was relayed to other agencies involved with Jessica’s care and a multi-disciplinary meeting was held shortly before her death.

A mental health nurse who had treated Jessica as an inpatient said, in a statement read by the Coroner, that no one could elicit a reason as to why this date would be significant to Jessica.

She added that Jessica had spoken about suicide in almost every chat with staff over the years – and had often set dates in these conversations. During the meeting, discussions were had over whether Jessica needed to be admitted to hospital, or have further involvement from the crisis team – but it was decided that Jessica’s thoughts and presentation were normal for her and that this was unnecessary.

The nurse then contacted Jessica to make her aware of support she could access, and to try and help her through the weekend. Jessica said she felt her new medication was contributing to suicidal thoughts, so the nurse agreed to contact a consultant to arrange a prescription for Diazepam.

The last time she spoke to Jessica, she had been on the phone with her GP to discuss the new medication. The nurse said this was evidence of forward planning, which indicates that a person suffering from mental health issues can see a future, and is not hopeless about their situation.

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A post-mortem examination found that Jessica’s cause of death was asphyxia due to gas inhalation.

Concluding, the Coroner said that Jessica had a “long history of mental health issues” and had spent time in hospital for treatment. She added that while Jessica had “clearly expressed that she had plans to end her life”, this was “appropriately discussed” by staff involved with her care – and that there were “no acts or omissions by the mental health team that caused or contributed to Jessica’s death.”

Jessica’s death was listed as suicide, and Assistant Coroner Evans said: “Having considered the evidence, I’m satisfied that not only was this a deliberate act, but it was done with the intention of dying.”