Abbigail Smith (3)
27 May 2026 · Coroner Sonia Hayes · Essex
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. insufficient trained staff for enhanced observations
“There were not sufficient trained staff to conduct the enhanced observations required to monitor Abbi with her known risk of severe self-harm whilst she was awaiting assessment under the Mental Health Act and actively attempting to take her own life”
2. inappropriate security staff observation
“Abbi was left under the observation of staff that were security personnel and were not appropriate or trained to undertake this work”
3. access to ligature material
“Abbi was able to access ligature material that she tied around her neck on multiple occasions over multiple days including her socks, cords from her clothing and pull cords in the bathroom”
4. lack of communication adjustments
“No adjustments or plans were made for communication for Abbi as a patient with Autism and learning difficulty”
Linked reports
Closely relatedConfidence 0.92 · high
Earlier report
“The acute care healthcare professionals do not have specialist mental health training to conduct a mental health assessment and the consequential presenting harm.”
This report
“There were not sufficient trained staff to conduct the enhanced observations required to monitor Abbi with her known risk of severe self-harm whilst she was awaiting assessment under the Mental Health Act and actively attempting to take her own life.”