HM Assistant Coroner Chipperfield – Oxford Coroner’s Court, 17th – 21st October 2016.


Rory Badenoch represented the family of the deceased, Debbie Yalcin, at a five-day Article 2 Jury inquest into the circumstances of her death when she stepped in front of a train at Didcot Parkway Railway station on 3rd December 2015, having recently absconded from the John Radcliffe Hospital.

At the Art 2 inquest, the clear focus was on establishing how a patient known to be actively suicidal, acutely psychotic, a high risk to herself and others, to have no insight into her condition or capacity to consent to treatment, to have refused admission and medication, and above all to be at high risk of absconding, was allowed to walk out of the hospital unnoticed despite having been assessed as requiring detention under s2 of MHA for her own safety.

In other words – why was the very thing she was being detained to prevent allowed to happen?


On 30/11/15 Mrs Yalcin attended the Princess Royal University Hospital having self-harmed by cutting her wrists. She had written a suicide note. She was noted to have been hearing voices for 2 weeks which were telling her to harm herself.

Following a review by a psychiatric nurse who recorded that she was suffering from “psychotic features” she was discharged to the care of the psychiatric home treatment team “HTT”.

The following day she was discharged from the care of the HTT following a telephone call in which she stated that she was better and did not need care.

On 2/12/15 Mrs Yalcin was attended to by police at the Ramada Hotel in Oxford having again sliced her wrists with a razor blade. She refused medical and police assistance, but it was decided that she lacked mental capacity sufficient to make decisions in respect of her own care and she was restrained and taken to hospital with a police escort.

On route to hospital she attempted to leave the ambulance and had to be restrained by a police officer.

On arrival at the John Radcliffe hospital she was assessed as lacking capacity under the Mental Capacity Act. She was deemed to be at “High risk of absconding” and specialist psychiatric review was arranged. In accordance with the MCA assessment she was not allowed to leave the hospital.

Following psychiatric review she was assessed as being “acutely psychotic”, hearing voices that were telling her to kill herself. A risk assessment deemed her to be actively suicidal, to lack capacity, to be a high risk to herself and a risk of absconding from the hospital.

A Mental Health Act [“MHA”] assessment was duly arranged.

Police remained with Mrs Yalcin to ensure that she did not leave the hospital and cause further harm to herself.

Before the Mental Health Act assessment was started the police were told that their attendance at the hospital was no longer needed, but before they left one of the attending police officers told hospital security that a MHA assessment was being undertaken and a member of security attended Debbie to note what she looked like with the intention that she would be recognised if she tried to leave.

No further security arrangements were made.

During the MHA assessment (conducted by two psychiatrists and an Approved Mental Health Professional) she presented as acutely psychotic, with the delusion of a demonic presence within her that was telling her to kill herself. She refused medication and admission and had little or no insight into her illness. Such insight as she did have was “fleeting”, and it was agreed that she lacked capacity to consent to a treatment / management plan.

The unanimous decision was that she needed to be sectioned under s2 MHA 1983, on the basis that she was suffering from mental disorder of a nature and degree which warranted her detention in a hospital for assessment in the interests of her own health and safety, and for the protection of others.

Arrangements were put in hand to transfer Mrs Yalcin to a secure psychiatric hospital for formally admission under the provisions of s2 MHA. Whilst awaiting transfer to a specialist unit she was placed on the Emergency Assessment Unit [“EAU”] (a non-secure ward). She remained under the provisions of the MCA and was not allowed to leave the hospital.

There followed a delay in finding her a bed at an appropriate psychiatric unit and she had to remain in the EAU overnight where she was left under the supervision of an EAU nurse who had 4 other patients.

The evidence of the nursing staff was that whilst they were aware that Mrs Yalcin remained subject to the Mental Capacity Act and was not allowed to leave the hospital, and that she was to be detained under s2 MHA, they were not informed following the MHA assessment about the nature and extent of her psychosis, her history, the fluctuations in her insight, and the risk of her absconding. Accordingly they were not aware that she might actively seek to leave the hospital undetected, and continuous observation and / or 1:1 nursing care (which could have been provided) was not deemed to be necessary.

At approximately 0655 on 3/12/15 nursing staff were attending to other patients and Mrs Yalcin was able to stand up and walk out of the hospital unnoticed and unchecked.

Soon after a search of the hospital commenced but she could not be found. She boarded a bus and travelled to Didcot Parkway station where she stepped in front of a passing freight train and died from multiple injuries.


The jury concluded that:

“There was a failure in the system to offer one to one care after Deborah had been assessed to be in need of admission to a hospital under s2 MHA and this factor contributed to her death and amounted to neglect.

Other contributory factors were:

1. A missed opportunity following the MHA assessment at the Princess Royal University Hospital;
2. Inadequate detail provided in handovers;
3. Lack of guidelines for patient care and security procedures following section 2 assessment and plan for admission
4. Lack of note reading by nursing staff relating to s2 assessment.

Deborah Yalcin died by suicide to which neglect contributed.”

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