Hilary Chapman
16 Sept 2025 · Coroner Simon Connolly · County Durham and Darlington
The coroner's concerns
1. lack of policy reference to new leave processes
“the overarching and updated section 17 leave policy makes no reference to these new processes”
2. patient under section 3 left unsupervised
“[the deceased] was under a section 3 at Lanchester Road Hospital for her depression”
3. patient found deceased in car park
“[the deceased] was found in her own car in the car park at Lanchester Road on 24/2/25”
4. delayed critical care after cardiac arrest
“[the deceased] had return of circulation from CPR and was transferred to CDDFT ITU where she received care to stabilise her cardiac output”
5. extensive hypoxic brain damage
“[the deceased] had a CT head 28/2/25 which showed extensive Hypoxic brain damage”
6. family involvement in best interest decision
“Best interest decision was done with her sister who felt [the deceased] would wish for”