The death of a 32-year-old woman in Durham was contributed to by police, a mental health trust and the Department of Works and Pensions, an inquest has found.

A post-mortem examination found that Sarah Holmes died from self-asphyxiation at her home on July 11, 2022. She had a history of mental health difficulties and self-harm, but family and friends describe the young woman as “vibrant and intelligent”.

Now, at an inquest heard at Crook Coroner’s Court, assistant coroner Janine Richards has said that the young woman’s death could have been prevented, but “political forces” between agencies came into play.

“Missed opportunities” by Durham Constabulary; Tees, Esk and Wear Valleys NHS Trust (TEWV); and the Department for Work and Pensions (DWP) significantly contributed to the likelihood of Sarah taking her own life.

Before her death, Sarah had secured a position to help others. She was going to become a “lived experience” worker for TEWV mental health trust, determined to use her experience with mental health to help those who found themselves in a similar position to her.

However Sarah’s mental health deteriorated in July 2022. The court heard that the DWP had been in touch with her, saying that they were reviewing her benefit payments, and may take action, after she “worked slightly too many hours, and earned slightly more” than she was supposed to.

In the days preceding her death, Sarah had tried to take her life in four different ways, eventually being rescued by police from the side of a road after concerned members of the public raised the alarm.

Coroner Janine Richards said concerns about her benefits, having to repay the money, and being seen as dishonest were “a major contributing factor to her mental health deterioration”.

But a string of inter-agency failings and “missed opportunities” meant that Sarah was able to take her own life at home only a day after her rescue on July 10, 2022, the inquest heard.  

Due to a staffing shortage at the crisis team, Durham Police took Sarah to A&E at North Durham Hospital for an emergency mental health assessment.

At hospital, she told the mental health liaison worker: “When I say that I am struggling, I really mean that I am in crisis, but I cannot say that so directly.”

Sarah said it felt like a “motor was running in her stomach that she could not switch off”, and that her attempts with her usual “self-soothing and grounding techniques had not worked”.

Still, Sarah was discharged to her home by staff. Her friends and family, “who could have provided valuable support”, were not told of her suicide attempts.

That evening, she failed to answer calls from her mental health care coordinator, and police were asked to perform a welfare check on the young woman – but “political forces” came into play, and the call handler “pushed back”.

Witnesses told the inquest that recent messaging from police leadership to the call room had outlined beliefs that “partner agencies were choosing not to attend incidents themselves, but pass risk to police, even if they are not the most suitable service.”

The force was “seeking that other agencies retained ownership” of cases, as they were concerned that police were “deemed to assume duty of care” in instances where they responded.

When Durham Constabulary was again contacted by mental health professionals for assistance, they again refused, saying that they “had no power”, and reiterating that TEWV had already seen the risk in the case lessen as they had discharged her.

The coroner outlined that “political forces were at play in this refusal”, and though the Independent Office for Police Conduct has since made recommendations to the force about their decision to not deploy officers or force entry, she was not satisfied that these had been accepted, or that leadership had reflected on the case.

When officers finally attended Sarah’s home after her father got in touch, worried for her welfare, they did not force entry but were let in by a friend with a spare key.

An officer told the court that they only had powers to force entry “only when an officer looks through a window and sees someone attempting to take their own life”, but assistant coroner Janine Richards said this was “not the case”.

Upon entry, they found her deceased, 17 hours after the first request for a welfare check.

The coroner had concerns about all three agencies in the case, outlining worries about how DWP had communicated with an individual they knew to be vulnerable; about TEWV’s choice to discharge Sarah without contacting her family and with an “inadequate” safety plan that “underestimated risk”; and about Durham Constabulary’s refusal to assist partner agencies.

During her narrative verdict, Ms Richards said: “There was a real and immediate risk of harm that was known or should have been known to police and mental health services.

This “inadequate” plan was borne of an “underestimation of the risk of her acting impulsively”, and though there was a “significant opportunity to involve her family and friends”, these were not taken.

Ms Richards said: “Her actions escalated in the days before her death, with new ways of harming herself that were starkly different to what had gone before. There were missed opportunities with this escalating risk. I cannot say that this would have saved Sarah, but it could have done.

“It is possible that a more timely and proportionate response may have prevented Sarah’s death.”

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Prior to the inquest, the coroner had written a Prevention of Future Deaths report after TEWV had failed to file a serious incident report about Sarah’s death 13 months after it was due.

Three more reports are set to be published about Sarah’s death, to be sent to the DWP, TEWV, and Durham Constabulary.

The agencies will be expected to respond within 56 days of the reports’ dates.