Hollie Loraine

“The MATTERS OF CONCERN are: On the day of her death, [the deceased] telephoned the North East Ambulance Service NHS Foundation Trust's 111 service at 05.22 hours. [the deceased] indicated that she was feeling suicidal and had made her mind up over the last 5 days. She stated that she had a noose around her neck and was about to jump. She added that she did not need an ambulance but needed someone to cut her down. Later in the call she said that she would get herself down. The call handler confirmed that an ambulance was in place. [the deceased] then referred to having a team involved with her but that whilst it was helping it didn't change the situation. The call handler reassured [the deceased] that help was in place for her and confirmed that the door to the property was open. The call handler then said, "I can let you go now that I've got that help in place, is that alright?" [the deceased] said thank you and, after being told to ring back if her condition got worse or had new symptoms, [the deceased] ended the call.”

“I am concerned that the evidence revealed that the national NHS pathways telephone triage system provides no guidance to health advisers dealing with such calls about whether to maintain telephone contact with a patient who is clearly expressing suicidal intent and, if maintaining contact, how to do so to ameliorate a risk of that patient ending their own life.”