Hatfield woman, 23, took her own life at railway station, coroner concludes
PUBLISHED: 13:02 14 June 2017 | UPDATED: 13:03 14 June 2017
A “beautiful and intelligent” Hatfield woman took her own life after being released from care without vital parties being present at a key meeting, a coroners’ court heard.
Coral Moon, 23, suffered from a “vicious circle” of drug abuse and a personality disorder, and was judged to have committed suicide after she was struck by a train at Hatfield railway station during the early hours of December 8, 2016.
In one of numerous spells in the care of mental health services, Lemsford Road resident Miss Moon had been detained on November 13 in Hertfordshire Partnership NHS Trust’s Swift Ward.
Dr Darwin Buyson, who investigated the care provided, said a “discharge meeting” in which it was decided Miss Moon could be released was held without all the relevant parties being present.
Coroner Geoffrey Sullivan added: “Her care coordinator wasn’t at that meeting, neither was the drug and alcohol team, nor was the CATT team.
“But she was at that meeting requesting discharge and she was deemed by her doctors to be stable for discharge.”
He added that descriptions of Miss Moon’s stay, which included an altercation with another patient, did not sound like someone who was becoming stable for discharge.
The court also heard that Miss Moon’s mother repeatedly tried to warn staff of her daughter’s suicidal threats, but none of her calls were returned.
Shortly after being released, friends and family alerted authorities to a video Miss Moon had posted on YouTube, in which she again stated her intention to take her own life.
But after attending the house and unsuccessfully attempting to talk to her, the mental health services deemed the threat of suicide was not “imminent”.
Coroner Sullivan added: “On this occasion it was felt that there wasn’t that imminent threat that was needed to detain her against her will, as there had been on the 13th of November, when she was actually walking to the railway with stated suicide intentions.”
Miss Moon’s mother described her as a “beautiful, intelligent, witty writer and poet, who wanted to get well and ultimately help others”.
She also told the court that she hoped lessons had been learned from the ordeal.