Louise Crane Inquest: NHS Trust Criticised for Care and Risk Failures

An inquest has concluded that the death of 39-year-old Louise Elizabeth Amy Crane, who died by suicide while under involuntary admission at Highgate Mental Health Centre in September 2024, was contributed to by significant failings in care by the North London NHS Foundation Trust.

Following a seven-day hearing at Bow Coroner’s Court, the jury – in front of Assistant Coroner Ian Potter - found that Louise’s death was the result of a combination of her high suicide risk linked to Emotionally Unstable Personality Disorder (EUPD) and systemic failures in her care.

On June 10th, a jury found that the factors contributing to her death were a chronic high risk to suicide linked to Emotionally Unstable Personality Disorder, in combination with unsatisfactory information sharing and recording, inadequate risk management, staffing and levels of care and treatment from Highgate Mental Health Centre, part of North London NHS Foundation Trust, during Louise’s time on Topaz Ward.

The family is represented by Kim Vernal, Head of Actions Against the Police and Stephen Clark of Garden Court Chambers.

Following the inquest, Louise’s family said:

"Louise was a much-loved daughter, sister and auntie, an incredibly intelligent and talented person, and we miss her presence every single day. She was hugely loyal to her friends and family, caring deeply about everyone. This included her beloved cat Loki, her comfort, whom she doted on. We will continue to feel the loss of Louise for the rest of our lives.”

"We came into this inquest expecting to hear about some problems surrounding Louise's treatment, but never did we expect the failings to be as bad as they were.”

“We are shocked and horrified by the extent of the lack of care, leadership and professional responsibility, which was consistently demonstrated by the staff on Topaz Ward. Louise should have been kept safe and looked after in hospital but was not, and we believe that she has lost her life because of these failings.”

"Additionally, we are appalled at the NHS Trust's conduct during this process. The obstructive, evasive and shambolic way in which the Trust has engaged with the inquest, seeking to minimize evident failures at every turn, has only added to the family's pain. The Trust sought to undermine its own internal review, which took some responsibility for the failings in Louise's care. We take from this that, publicly at least, the Trust continues to avoid accountability for its substandard care. The Trust has shown itself to be indifferent to the consequences of its own acknowledged failings.”

"What is especially upsetting for us is that Louise had been showing positive signs of recovery prior to her admission to Topaz Ward, giving the family hope for the first time in a very long while. That hope has been taken from us, with Louise failed in her care when it was most critical."

The family ask that their privacy is respected in this difficult time.

Kim said: “The sheer number of poor practices revealed during Louise’s inquest is disturbing. This included deficiencies in information sharing, risk assessments, care and treatment, all stemming from poor leadership. The jury concluded that these deficiencies were contributing factors to Louise’s death.”

“The very systems that should have been in place to protect Louise failed her when she was at her most vulnerable. It is imperative that the Trust reflect upon the jury findings and the Prevention of Future Deaths report HM Coroner will be issuing to ensure that the safety of other vulnerable patients is better protected in future," she concluded.

The Inquest

During the seven-day hearing, the jury heard the following evidence from ten witnesses, in addition to multiple statements read out by the Coroner.

It found that the documentation of Louise’s care on the acute ward was significantly below acceptable standards. Multiple witnesses acknowledged that record-keeping was inadequate, resulting in the loss of critical information regarding her risk to herself. Risk assessments were updated only twice during her admission, and even then, they failed to clearly identify the nature of the risks or outline appropriate responses. No individualised risk management plans were developed or recorded. Instead, Louise was treated as a “standard” patient, despite her complex and well-documented mental health needs.