A grieving mother has told an inquest of her disbelief that her daughter was released from a psychiatric ward despite having told staff that had thoughts about taking her life and had a ‘stash of pills’ at home.

Emily Hemingway was found by a dog walker on the banks of the River Cleddau, near Haverfordwest Priory on September 23, 2020.

The inquest heard how Emily was a ‘brilliant, bright and intelligent girl’, an avid reader who was dearly loved by her family and friends.

Her mental health had started to decline at the age of 16.

She was later diagnosed with unstable emotional personality disorder and experienced episodes of severe self-harm, feelings of low self-worth and attempts to end her life.

An inquest on Thursday, July 11, heard that the Covid lockdown and the break-up of a romantic relationship had both had effects on her mental health.

On September 9, 2020, just a week after her 27th birthday, Emily was admitted to St Caradog at Bro Cerwyn, Haverfordwest after an incident at the town’s multi-storey car park.

During her time there she told staff that she had thoughts of ending her life and that she had a stash of pills to do so.

Emily’s mother, Wendy Hemingway, told the inquest that her daughter had rung from the hospital saying repeatedly: "I need help."

On her release she went to stay with her mother for the weekend but needed to return to her Haverfordwest flat to meet with the crisis team and pick up her medication from them.

During that weekend she expressed feelings of hopelessness saying: "There is no hope. No one is ever going to help me.”

Emily returned to her flat on September 21, insisting that she needed a couple of days to herself.

She was found two days later. A letter stating her intention to end her life was also found.

Her mother Wendy said that she was shocked that Emily was released from hospital when staff knew she had a stash of pills.

“I find that astonishing. I didn’t know about that stash. I would have removed it from her flat,” she said. “Had I known it was there, the last thing I would have done was drop her off at the flat. I can’t believe they decided that it was okay to leave that stash with her.”

Emily Barnett, trainee clinical psychologist for Hywel Dda Health Board told the inquest that she spoken with Emily several times during her stay on the ward.

During their first meeting on September 14, she was distressed at the prospect of being discharged however at subsequent meetings became more positive about the prospect and was discharged on the 18th.

Emily had disclosed that she had a stash of medicine at home and was "very clear that she found it anxiety provoking for the medicine to be taken away".

Rhys Bevan, consultant psychiatrist for the health board told the hearing that it was not unknown for people with EUPD to have a means or method of suicide to hand, and that sometimes removing it can increase stress.

However, he admitted: “I can see from the notes that I was aware that she had a stock pile. I cannot offer an explanation as to why I didn’t explore that with her myself. I regret not doing so... Had we asked her and had she been willing to hand the medication in, we could have done that. Had she been unwilling it could have left us in a tricky situation."

Dr Bevan also apologised that Emily felt rushed during a meeting with him prior to discharge. She had written down things that she wanted to say in a letter and Dr Bevan had asked her to summarise.

Mr Howells for the Health board asked Dr Bevan if Emily had had a high level of contact with both himself and the clinical psychologist to which he replied yes.

Mental health advocate Ed Latter said that the document would have taken about ten minutes to read aloud and effectively expressed Emily’s thoughts and feelings about self-harm, not wanting to live and suicidal ideation.

Mr Latter said that he had tried to summarise the key points including how Emily’s feelings about suicide had changed and how that scared her.

He added that he had not initially been told about the meeting, despite letting staff know the day before that Emily had asked for advocacy.

“I now know, although I wasn’t aware at the time, that Emily felt rushed,” said Dr Bevan. “I’m very sorry about that.”

He added that on considering Emily’s discharge, the positive, protective factors in play were factored in. The fact that she had insight into her situation, was going to stay with her mother and was able to employ strategies when experiencing negative thoughts.

Community psychiatric nurse Shelly Arran said that she had arranged for Emily’s medication to be delivered to her flat on September 21. On the 22 she had visited Emily at home. She had music playing and had been burning incense.

“She was quite relaxed and seemed really well,” she said. “She said she didn’t have thoughts or plans to hurt herself. She was quite excited as she was going to see a friend to give her a birthday present. There were no concerns.”

Ms Arran tried to contact Emily again on the 23rd over the telephone and by visiting her flat. She was not successful but thought that Emily had stayed longer at her friend’s house.

The hearing will continue tomorrow, Friday, July 8, when an expert witness report and evidence from police officers will be considered.

  • If you are affected by any issues raised in this article, Samaritans (116 123) operates a 24-hour service available every day of the year. If you prefer to write down how you’re feeling, or if you’re worried about being overheard on the phone, you can email Samaritans at jo@samaritans.org.