Jennifer Mary Semple known to her friends and family as Jen died on 4th August 2019, at just 25 years old. An Inquest into her death concluded on 8th March 2022, finding that a missed opportunity by her local NHS Trust’s Crisis Line contributed to her death, and ultimately ruled her death was as a result of ‘suicide in part contributed to by neglect whilst suffering from poor mental health’.

Jen had had several interactions with staff from North West Boroughs Healthcare NHS Foundation Trust (now Mersey Care NHS Foundation Trust) in relation to her mental health over the course of the year prior to her death. At the conclusion of the Inquest, the Coroner found there was a missed opportunity to ensure Jen was safe by sending an ambulance to her home when she called the Trust’s Crisis Line following an unsuccessful suicide attempt.

The Coroner also noted the following failings in respect of Jen’s mental health care but could not be sure if they caused or contributed to her death:

• There was a delay in Jen’s clinical care being discussed at the Assessment Team Multi-Disciplinary Team Meeting.
• A Multi-Disciplinary Team Meeting which took place on 10th July 2019 did not discuss Jen’s medication and as such was not as effective as it should have been.
• There was a lack of escalation with regards to Jen’s reports that she had attempted suicide on 4th August 2019; however, it is unclear as to the precise time she died such that the escalation may not have made a difference but might have alerted her loved ones to her plight earlier
• The clinical service was using historic documentation with the incorrect Trust details; and
• Jen’s anti-depressant medication was not reviewed in line with NICE Guidelines.

Clair Hilder, Inquests Team Head at Broudie Jackson Canter, and the Solicitor representing Jen’s family explains:

“When Jen called the crisis line on 4th August 2019, she needed urgent medical assessment. Instead, she was told that there would be a follow up call later that day. The findings of this inquest are a damning indictment of a system that was tragically and avoidably unsafe. Because of the failure to send an ambulance to Jen, her family underwent the trauma of finding her body. Both Jen and her family deserved so much more.”

Jen is dearly missed by her family, who are determined to ensure no other family has to experience the loss of a loved one due to similar failings.

Jen’s family said:

“Jen was a beloved daughter, sister, niece and cousin. She was kind, thoughtful and approachable to all who met her and a champion for anyone who was going through difficult times. It was only after Jen’s death that her family were made aware of all the people who she had supported. Even though Jen was dealing with her own issues, she touched the lives of so many others. It was a balm for her Mother and family to see all the people who attended her funeral and made sure her Mother knew how much of an impact Jen had made on their lives. As a family we are so very proud of Jen and her achievements and although we only had her for 25 years she will be loved and missed forever.

We hope that through the inquest process lessons have been learnt so that the failings in Jen’s care are not repeated and no other family needs to go through what we have.

We would like to thank our lawyers at Broudie Jackson Canter, our barrister, Ciara Bartlam, and the charity INQUEST for their support. We believe without access to legal representation paid for by legal aid we would not have achieved the result we have through the inquest process. We are aware that many bereaved families do not have access to the support we have had.”

Clair Hilder is an Inquest Team Head at Broudie Jackson Canter helping bereaved families seek justice. 

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