This inquest focused on the actions taken by the University of the West of England (UWE),  Surrey Police, and Avon and Somerset Constabulary when informed that AL had overdosed. Though categorised as an Immediate Response (Priority 1 emergency) the jury found that a “catalogue of missed opportunities” caused delays in help reaching AL, which led to her tragic death. Numerous causative failings were identified by the jury in relation to communication between agencies and efforts to identify AL’s current location.

HM Coroner made a PFD to the College of Policing, and to the Chief Constables of Surrey Police and Avon and Somerset Police due to the following concern:
“With limited or no guidance, training or policy on when police and/or police support staff liaising with the public should leave a voicemail (particularly in circumstances where they are trying to obtain important information in a time pressured situation), I am concerned that there is a risk that future deaths will occur unless action is taken, and in the circumstances it is my statutory duty to report to you.”

The Record of Inquest included the following findings by the jury:

The arrival of emergency services was delayed because of a catalogue of missed opportunities to obtain A’s correct address.

There were failures by the security and OOH teams at UWE to access A’s current address.

There was insufficient and inaccurate observation of the Kenetics and ISIS records.

Communication between UWE security and Surrey Police was misleading and lacked clarity

UWE security team’s statement that there was “no apparent cause for concern” led to Surrey Police closing the incident without having confirmed that A was safe and well.

Following the initial call from an informant to Surrey Police, Amy’s home address in Surrey was identified. Failure to act on this information caused a critical delay.

The continuing call between the informant, A’s friend and police gave information which aided efforts to reach Amy and led to the re-opening of the incident.

The emergency contact details were passed on to ASC. Continuing failings led to more delays. The sense of urgency seemed to have been lost.

A’s mental health issues contributed to her actions on 18 June 2023.

Based on expert opinion and all the evidence we have heard, the balance of probabilities suggests that A would have survived if she had received paramedic attention prior to her cardiac arrest.

It is probable that AL would have received attention from paramedics prior to her cardiac arrest if not for the missed opportunities prior to her cardiac arrest if not for the missed opportunities we have identified.

Read the Prevention of Future Deaths Report here. 

For further enquiries about Isabel, please contact Practice Manager Scott Haley [email protected]

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