Thread by @SashaInquest

We're back in court at the end of the inquest into the death of Sasha Forster.

Coroner: Can I ask please jury bailiffs have you returned the jury in accordance with the oaths you've taken

They have

Coroner: Have you reached conclusions in respect of all aspects of the form

Jury: Yes we have

Coroner: Are they conclusions of you all in every case

Jury: Yes

Coroner: Section 1?

Jury: Sasha Sabrina Forster

Coroner: Cause of death

Jury: Drug 1 poisoning

Jury: Sasha died at 21:00 hours on 31 March 2017 at Frimley Park as a result of deliberately ingesting a fatal overdose of Drug 1 tablets

Jury read Section 5 particulars

Coroner: Your conclusion in Section 4 please

Jury: Sasha Forster died as a result of suicide following her deliberate ingestion of Drug 1 tablets

Coroner: Members of the jury can I thank you for your hard work in this case, it's been a long case, there's been a lot of evidence. The application and dedication you've shown is very much appreciated. I hope you've found it an interesting and stimulating experiences

Coroner: Not every inquest requires a jury, in this case it was because Sasha was in state custody under detention of the MHA. It's important when someone is detained by the state that ordinary members of the public like yourselves make the final decision

Coroner: You should also know, I referred to it when I summed things up to you, that I have a duty if issue were raised during evidence heard that action needs to be taken that action needs to be taken to prevent deaths in the future about how the person came by their death.

Coroner: So thank you very much indeed. I've concluded in three respects I need to make reports directed at certain parties in the hope future deaths can be prevented. Those three areas are these:

1) to @sabpnhs and those responsible for funding that trust and also to @MattHancock I was concerned to hear evidence @sabpnhs were unable to fulfil their function to return to the ward patients whose leave has been revoked, they have a legal responsibility to do that...

so I'll ask what they'll do so they are able to fulfil their legal responsibility

2) the second area is this, i'm grateful to the letter from Deputy CEO of @sabpnhs this morning as its at their suggestion.

Coroner: I'm going to write to all trusts involved @sabpnhs @frimleyhealth @royalsurrey and police forces involved @hantspolice @surreypolice about need for collaboration between all those services to ensure a better coordinated response in situations when a person's Section 17

Coroner: leave has been revoked

3) Lastly you'll remember the evidence of the two private GPs who Sasha was able to get a prescription for Drug 1 despite it had been ceased to be prescribed. I've received a letter from @londondoctorscl where both those doctors were working.

Coroner: There are real practical difficulties about those GPs contacting Sasha's NHS treating team... patient confidentiality and barriers that would prevent a private GP doing that without explicit consent; the other way that GP would not have access to Sasha's NHS records.

Coroner: You'd hope a patient would be happy to give their consent, but there are no doubt cases where that is not the case, so I'm going to write a report to @gmcuk and @MattHancock to see what they can do to prevent that happening again

Coroner: It's as a result of the evidence that we have heard that I am able to do that.

There is one final matter, none of us who've heard the harrowing evidence in this case can fail to feel sympathy for Mr and Mrs Forster and the rest of the family...

Coroner: and those looking after Sasha, for the immense struggle they must have faced in looking after Sasha and the struggle they have faced since she died. Mrs Miles I hope you'd allow me to address your clients directly, Mr and Mrs Forster you have my sincere condolences...

Coroner: I hope the process, lengthy as it was, has provided some comfort to you

Coroner thanks jury and those who have helped the inquest.