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07 May 2021

Surrey Coroner writes Regulation 28 report to prevent future deaths following Hannah Bampfylde inquest

7 mins

Before HM Assistant Coroner for Surrey, Anna Loxton
Inquest: 30 March and 28 April 2021 (two day hearing)

Hannah Bampfylde was a 28 year old gym instructor from Horley, Surrey. After two days of evidence, the Coroner returned a suicide conclusion and made a report to the Chief Executive of Sussex Partnership NHS Foundation Trust, and the Chief Coroner of England and Wales, to prevent future deaths. This was after Hannah’s inquest raised concerns about how mental health referrals to Horsham Assessment and Treatment Service (ATS) are dealt with and engagement with patients’ GPs. 


Hannah Bampfylde had a long history of mental health difficulties and had been diagnosed with Borderline Personality Disorder. Following a settled period, Hannah’s mental health deteriorated following a relationship breakdown. This led to an attempted overdose in October 2019.

After this, Hannah was referred to Time to Talk, but she was deemed not suitable due to her diagnosis and recent suicide attempt. Hannah’s GP was concerned that she would be ‘dropped into limbo’. He referred Hannah to Horsham Assessment and Treatment Service for mental health input, which is part of Sussex Partnership NHS Foundation Trust (the Trust).

Hannah was booked for an initial assessment with Horsham ATS on 26 November 2019. Hannah did not attend and a further appointment was booked on 4 December 2019. However, Horsham ATS cancelled this at short notice due to a double booking and rescheduled this for 6 December 2019.

Hannah responded via text on 5 December 2019 asking what time the rescheduled appointment would be. Horsham ATS responded via text on 6 December 2019 at 09.27am to confirm that Hannah’s appointment was at 12pm that day. It is unlikely Hannah would have seen this text as she was already at work and did not finish until 1pm. Horsham ATS also did not record this information in Hannah’s case notes and instead inaccurately recorded that she had failed to attend her appointment on 4 December 2019. 

Hannah lost all faith in Horsham ATS and their lack of engagement with her. Hannah’s mother arranged private counselling for her with Care to Listen in February 2020, but her needs were too severe for their services.

No further appointments or action was taken to progress Hannah’s referral by Horsham ATS until March 2020, when a letter was sent to Hannah advising that she had missed two appointments and unless she made contact by 20 March 2020 that she would be discharged back into her GP’s care. Hannah had moved address, but did receive a copy of the letter when she attended Crawley Urgent Treatment Centre (UTC) on 5 March 2020 feeling low. UTC also emailed Horsham ATS about Hannah’s attendance, but they did not follow this up with Hannah and she did not contact them. There was also no multi-disciplinary meeting prior to Hannah being discharged from Horsham ATS on 1 April 2020. Hannah’s GP was not aware of this during his telephone consultation with Hannah on 7 April 2020.

Tragically, Hannah was found dead in her mother’s garage on 14 April 2020. Hannah’s relationship breakdown, lockdown and the death of Caroline Flack affected her mental health with no professional support.


After hearing evidence over two days on 30 March and 28 April 2021, the Coroner found that more should have been done to support Hannah under the Trust’s own active engagement policy before discharge.

Horsham ATS had failed to record important information in their own records, including that they had rescheduled Hannah’s appointment in December and failed to follow this up with a further appointment when Hannah failed to attend. The assessor and care co-coordinator at Horsham ATS also failed to record their apparent discussion about Hannah in March prior to discharge.

Despite these missed opportunities, the Coroner found there was not sufficient evidence before the Court to conclude that the lack of assessment by Horsham ATS caused or contributed to Hannah’s death, but the evidence did highlight a lack of clarity and potential for persons newly referred to not engage without their GPs being made aware of this. The Coroner found that Hannah had taken her own life and returned a suicide conclusion. On the Record of Inquest, the Coroner recorded:

‘On 14th April 2020, Hannah Bampfylde was found hanging by the neck in the garage of her Mother’s home address in Horley, Surrey, and ROLE was given by attending paramedics at 16.15. Ms Bampfylde had a history of mental health problems and had sought help for this. She was diagnosed with Borderline Personality Disorder. Following a suicide attempt by overdose in October 2019, she was referred to Time to Talk Service, but this referral was rejected as too severe due to her suicidal ideation, and she was given a routine referral to Horsham Assessment and Treatment Service. She attended the Urgent Treatment Centre in Crawley on 5th March 2020 for volatile mood and sought private counselling, but was subsequently discharged from Horsham Assessment and Treatment Service back to her GP on 1st April 2020 without having been assessed. A note was found in her bedroom dated 26th March 2020 stating that she did not feel able to carry on living.’

The Coroner also made a Regulation 28 report to prevent future deaths to the Chief Executive of the Trust on 5 May 2021, due to concerns that there was a lack of clarity on procedures at Horsham ATS when a person was referred and did not engage. Specially, the Coroner was concerned that:

  1. Appointments are not automatically re-booked when a person has failed to attend an appointment;
  2. it is not clear who should rebook appointments when a person failed to attend;
  3. GPs are not routinely notified if a person has not attended an appointment with Horsham ATS, meaning the GP would be unaware that the person was not receiving input until they had failed to attend a number of appointments and were discharged back to primary care, potentially many months after being referred.

The Trust has 56 days to respond to the Coroner’s concerns and consider whether any steps can be taken to address the Coroner’s concerns.   

Louise Ray, mother of Hannah Bampfylde said:

Nothing will bring Hannah back to us. The inquest outcome matters to us for two reasons:

1. Absolutely everything should be done to prevent avoidable deaths being repeated. It is not just about family and friends and their terrible heart breaking grief. It is about the individual too – the life that they could and should have had. And might have had if different actions had been taken.

2. Hannah was such a huge advocate for people with mental health difficulties. She would always try to support those who were struggling despite her own difficulties. I cannot think of a more fitting tribute to my beautiful daughter than being able to prevent someone else’s death. Hannah would be so proud.

Bindmans Partner, Anna Thwaites, who is representing the family, said:

Hannah was a keen mental health advocate. When Hannah was in mental health crisis, she would pull through with support.  Sadly, it appears that Hannah fell through the cracks and did not receive any support from Horsham ATS prior to her discharge.  It is hoped that the Trust will carefully consider the Coroner’s Regulation 28 report to prevent future deaths to improve their new referral system and engage with treating GPs to help support and protect those who are mentally vulnerable.

The family is represented by Anna Thwaites of Bindmans LLP and Tom Stoate of Doughty Street Chambers.

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