Thread by @SashaInquest

Coroner: Could I ask you please to turn to p8 of your bundles, this is another little document you may find useful referring to as we go along, it sets out the various parties involved, the key witnesses, who they are and what they do

Coroner: p11 then pls, let's work our way through the chronology.

Again, this is an agreed chronology, so again it is, it may be useful to you as you hear evidence about events on a particular date, you can refer back to remind yourself what happened immediately before or after

Coroner: Sasha had review w Dr Shuttleworth and decision made prescribe propranalol

30 Sept she took her first propranalol and paracetamol overdose
2 Oct she took second propranalol and paracetamol overdose and presented at Frimley Park

< other instances - missed >

Coroner:
25 October attended A&E following propranalol and paracetamol overdose
26 October attended A&E following paracetamol overdose, told hospital had also taken propranalol

30 Nov attended GP clinic with Dr Hooda - prescription for 28 days

4 Dec attended Frimley Park following overdose
13 Dec attended GP clinic with Dr Sills - prescription
18 Dec attended Frimley Park A&E following propranalol and paracetamol overdose
21 Dec treated in resuscitation at Royal Sussex Hospital in Brighton

22 Dec detained under section 2 of MHA
23 Dec Sasha took paracetamol overdose on Mulberry Ward while in hospital, had not been searched on return from leave
27 Dec Sasha attended Frimley Park while on Section 17 leave following propranalol and paracetamol overdose

28 Dec she was discharged from section
29 Dec attended Frimley Park following propranalol overdose
2 Jan (?) attended Frimley Park A&E after propranalol

10 Jan - Sasha attended A&E, CPR was undertaken, admitted to ICU
13 Jan - assessed in the ICU and detained under Section 3 of MHA
16 Jan - moved to Mulberry Ward
20 Jan - leave granted up to 2hrs, up to three times a week

30 Jan - Sasha self harms on Mulberry Ward with safety pin that she then swallowed, granted leave to attend A&E with staff member and her mother

Sasha absconded - deemed AWOL by ward, police informed, remained so until 7 Feb

1 Feb - Sasha reported AWOL to @surreypolice after she refused to return to Mulberry Ward from home. @Surreypolice advised was ward's responsibility to return Sasha to ward and if police assistance was required it would be @HantsPolice

1 Feb - later that night Sasha attended Frimley Park after self harming
2 Feb - Sasha attended @royalsurrey hospital with laceration to right arm
3 Feb - had to apply Section 135, no appointment at Magistrates Court until 6 Feb; Sasha absconded as parents attempted return to ward

4 Feb - Sasha was found in London and returned
6 Feb - Section 135 was
7 Feb - Section 135 warrant was executed and Sasha returned to Mulberry Ward, she'd been AWOL since 30 Jan;

on her return to ward 3 empty paracetamol packets were found, she disclosed she'd taken an overdose, was taken to A&E at @royalsurrey; later that evening she self-harmed on ward and she was returned to A&E where she absconded and reported to @SurreyPolice

9 Feb - Sasha returned home, was seen there by @surreypolice
12 Feb - Sasha self harmed at home while AWOL, returned to Mulberry Ward and placed on 1-1 observation

13 Feb - Steven Forster, Sasha's father, made application for her to be discharged from her section, withdrew application later that date, she was granted leave

15 Feb - Sasha attended placement with her care coordinator, two specialist placements and an autism assessment referral were discussed; on same date Angela Forster, Sasha's mother, had notified hospital about neurological issues Sasha was having

19 Feb - Sasha attended Frimley Park A&E with suicidal wards
20 Feb - Sasha attended Mulberry Ward with thoughts of self-harm
Home treatment team contacted
23 Feb - attended Frimley Park after paracetamol overdose

Missed date - Sasha attended with suicidal thoughts

26 Feb Sasha attended Mulberry Ward to speak with staff, half hour later attended @RoyalSurrey disclosed taken paracetamol overdose, deemed not have capacity, absconded, Police informed, deemed high risk missing person, Sasha returned home, ambulance staff deemed she had capacity

26 Feb - Sasha attended Frimley Park with her mother.
27 Feb Sasha absconded from Frimley Park, @SurreyPolice notified @hantspolice
28 Feb attended @royalsurrey after overdose while on Section 17 leave

<missed some>

3 Mar - Police located Sasha having taken overdose at Fleet Pond, taken to Frimley Park, returned to Mulberry Ward with her mother, absconded from hospital reception; police attended home and Sasha absconded when they arrived
5 Mar - Sasha returned home

6 Mar - Sasha attended Frimley Park to speak to psychiatric liaison; declined to speak to member of staff on duty; her mother contacted Mulberry Ward saying Sasha was threatening to overdose

7 Mar - Sasha returned to Mulberry Ward but granted leave; later that evening she attended Frimley Park, referred to psychiatric liaison, she reported she was contemplating a propanalol overdose

8 Mar - Sasha attended hospital with her mother, left hospital before seeing staff @surreypolice deemed her high risk missing person and later established she was at home

8 Mar - Sasha attended Mulberry Ward and stated she was struggling. She took a paracetamol overdose in the toilet on the ward; taken to @royalsurrey but absconded

9 Mar - attended Frimley Park with suicidal ideation; A&E department contact @surreypolice asking them to escort her back to Mulberry Ward, she absconded, @hantspolice don't deem her a missing person

10 Mar - Sasha returned to Mulberry Ward and said had taken propranalol that morning, given time passed was deemed unnecessary to attend A&E

11 Mar - Sasha self harmed on ward with a paperclip, was taken to A&E with 2 members of staff but absconded

13 Mar - Sasha granted Section 17 community leave for 2hrs to purchase food with her mother
14 March - granted up to 8 hours community leave between 14-21 March, rising to 12 hours although not clear from which date

17 Mar - Sasha attended second half of assessment for Hope House, granted overnight leave
18 Mar - returned as requested, overnight leave
19 Mar - returned as requested

21 Mar - attended A&E with suicidal thoughts, granted community leave to buy food and collect medication - signature of doctor unclear
21 Mar - attend hospital with suicidal ideation, left threatening a propranalol overdose

23 Mar - Sasha left Mulberry Ward for 2 days leave, met with police at Sasha's house
24 Mar - Sasha granted overnight leave to 26 Mar community leave to collect food and prescription; Sasha's mother contacted staff to raise concerns that Sasha was keeping propranalol on the ward

24 Mar - Sasha's room was searched and nothing found
25 Mar - attended A&E following paracetamol overdose
26 Mar - returned to Mulberry Ward and self-harmed

27 Mar - Sasha taken to @RoyalSurrey A&E by secure ambulance following paracetamol overdose previous day, refused treatment, returned to Mulberry Ward

28 Mar - Sasha refused to return to the ward after community leave; attended @RoyalSurrey with laceration, Mulberry Ward contact @surreypolice, they refer to @hantspolice who do not treat Sasha as a missing person

29 Mar - Section 17 leave plans discussed with Sasha and her parents - granted overnight leave from 12 noon until 11am on 31 Mar

Same day Sasha underwent an #ASD assessment and presented to Royal Berkshire A&E after making laceration to right arm

29 Mar - attended Mulberry Ward for 1-1 session with mental health nurse
30 Mar - Sasha's mother contacted mental health team and asked to speak to Matt, told unavailable, told to contact Mulberry Ward [?]
Sasha visited by Charlotte Tickner of Fleet Phoenix charity

31 Mar - Sasha attended A&E and asked to see psychiatric liaison; was not seen, Sasha told her mother she'd taken an overdose and an anti-sickness tablet

Just after 13:40 Sasha was detained by @HantsPolice about 14:05 police attended Sasha's address and spoke to Mrs Forster

14:30 Sasha left with her mother; just before 4pm she attended @royalsurrey A&E, refused to enter building but spoken to by senior sister, Sasha then ran away; deemed AWOL by Farnham Road hospital, called @SurreyPolice after Mrs Forster informed absconded

16:45 @SurreyPolice recorded Sasha as medium high risk; graded to high at 16:50; 16:55 Sasha spoke to police officer, expressed suicidal intention, said she intended to take beta-blockers in her possession, refused to disclose her location;

PC Saunders telephoned her 3 times, she did not answer; next call answered, 17:29 a live trace on Sasha's mobile is authorised, 17:47 @hantspolice notified by friend of Sasha's she'd posted a video on facebook

17:52 Surrey Police think Sasha may be at Woking Station, phones Sasha and hear's a train announcement in background, directs police to Woking Station, Sasha says she's taken an overdose refuses, disclose location; phone tracked in Fleet, think she's travelling home

18:35 Sasha speak to PC Saunders for third time, her speech is impaired, hears vomiting, says she's at Fleet Pond 18:50 Police arrive at Fleet Pond car park, 18:55 Surrey Police record reads as PC still on phone, says she's laying on bench, can see pond and train station

Police log says been 3/4 way around, can't see her; later deployed with drone, 19:04 Sasha located by police, 19:05 ambulance called, 19:11 starting CPR, breathing getting worse then better, erratic, 19:12 police log reads getting defrib; 19:25 ambulance service attend

19:45 ambulance service administer narox??? goes into CPR, taken by ambulance to Frimley Park Emergency Dept, 20:37 Sasha arrives, 21:00 Sasha was pronounced decesaed

Coroner: so ladies and gentlemen that is the chronology that hopefully sets the evidence in some context. The last thing we'll do this morning is ask Mrs Forster to read to you a reflective statement, give you an idea of Sasha.