The Independent London Newspaper


Coroner says Georgia Arnull’s hanging ‘misdaventure’

Student’s mother feels ‘let down’ by mental health services

Published: 23 April 2010

A STUDENT was found hanging by her dressing gown cord days after she told doctors voices were telling her to harm herself, an inquest heard.

Georgia Arnull, 20, was discovered suspended from a bannister by her mother in their Granville Square flat, Farringdon, in January.

Georgia, who had battled mental health problems since the age of 15, was seen by doctors from Camden and Islington NHS Trust twice in the week before her death.

Her inquest on Tuesday heard that her mother Kelly Gladwell had been so worried she had asked doctors to admit her daughter to hospital, but they did not think she was at risk of suicide.

Ms Gladwell told St Pancras Coroner’s Court: “I thought they would have put her in hospital because she was hearing voices. She told them the voices were telling her to harm herself. She was scared.”

In a statement read out by Ms Gladwell’s lawyer later, she said she felt “let down” by mental health services in Islington and was planning to sue the trust for negligence.

Georgia had been known to mental health services since 2005, but was referred to South Camden Crisis 10 days before her death after taking an overdose. She had also tried to slit her wrists with scissors, the inquest heard.

Dr Sarvenaz Keyani, who visited Georgia at home a week before her death, said: “She admitted hearing voices from the television and she believed people wanted to harm her. She said had had thoughts of suicide at times.”

But when doctors visited Georgia again four days later – three days before her body was found – she appeared “calmer,” the court heard. “She still had thoughts of suicide but didn’t have any intention to kill herself,” Dr Keyani said. “We didn’t feel she needed hospital admission. The decision was to see her again on Monday and contact her mother over the weekend.” 

The crisis team failed to contact Ms Gladwell and over the weekend she was so concerned for her daughter’s safety she slept in her bed. But when Georgia had a bath on Monday morning, Ms Gladwell dropped off to sleep on the sofa. 

When she awoke about half an hour later, she found her daughter’s suspended body.

Paramedics were able to restart Georgia’s heart, but her brain had suffered severe damage and she died the next day in hospital.

At the inquest Keith McCoy, assistant director of Islington mental health services, admitted their had been communication failures. 

He said a message instructing weekend staff to contact Ms Gladwell had been wiped from a white board without explanation, but said it had not affected the outcome.

“If at any time staff thought she was at risk, the interventions would have been different,” he told the inquest.

Recording a verdict of misadventure, coroner Dr Andrew Reid said: “Taking into account the fact that she was not alone, and given her past self-harming behaviour, I infer that she intended a cry for help. It was not necessarily her intention to end her own life.” 

Ms Gladwell said in a statement: “I am pleased with the coroner’s verdict as I never believed Georgia intended to end her life. I feel let down by the local mental health services and I hope that lessons are learned so that another family doesn’t have to suffer as we have. Georgia was a loving, fun sister and daughter and we miss and think about her every day.”

A spokesman for the NHS trust said: “We were saddened by the tragic death of Georgia Arnull, which the coroner recorded as misadventure. She was a popular service user, who had engaged well with our crisis and home treatment teams, and we knew the loving care and support her mother was giving her at home. Our thoughts go out to her mother, family and friends.”



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