SOMERSET NHS Foundation Trust has responded following the inquest into a 22-year-old Bridgwater woman who died a day after being discharged from a mental health ward.
From Monday, November 9 until Wednesday, November 11, the inquest for Abbie Louise Winn took place in Wells Town Hall, heard before Senior Coroner Samantha Marsh.
Following the inquest, the medical director for mental health and learning disabilities at Somerset NHS Foundation Trust offered her condolences to Abbie’s family and loved ones.
Alongside this, the Trust said they “welcome the coroner’s conclusions” and the findings of the inquest and are committed to providing safe care for everyone.
Previously, it was heard Abbie had been known by the mental health services since 2014, when she was 12.
Over the years, her anxiety worsened, and she experienced three “significant bereavements” and the end of a relationship, the court heard.
In March 2025, before her admission to a mental health ward, Abbie received unwanted contact from her ex-partner, which acted as a “catalyst”.
After mental health staff tried to calm a situation involving Abbie, Avon and Somerset Police were called and took her to Rowan Ward Two in Yeovil on March 19.
Ms Marsh acknowledged that Abbie voiced suicidal intentions when faced with discharge, but from the evidence heard in court, said the admission was never long-term.
The aim was to stabilise Abbie’s acute crisis before returning her to community care.
The court heard Abbie had chronic suicidal thoughts and made “some improvements” on the ward, but her behaviour and mood also worsened.
Abbie was initially due to leave on April 10, but her discharge was postponed more than once.
When discharge was discussed again on April 24, Abbie was encouraged to choose the date herself.
The date April 30 was eventually chosen.
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Whilst Abbie was not on board with being discharged, Ms Marsh told the court that Abbie could not identify anything that would get her ready for discharge.
She said: “I find the discharge on April 30 was appropriate. Abbie, as we heard, had chronic suicidal ideation that hadn’t changed during her admission.
“I find that, based on the evidence, the admission was not helping her. She had 12 self-harm incidents in six weeks as an inpatient, which is much greater than in the community.
“So, being an inpatient appeared to increase her risk of self-harm.”
Ms Marsh also told the court that Abbie did not want to leave the ward because she found it “safe” and did not have to face her real-life stresses.
The day after her discharge (May 1), Abbie had a meeting with psychiatric nurses at 4pm and left after voicing her suicidal intent at around 5.20pm.
The court heard that community nurses had no power to detain.
They could only keep Abbie talking for longer, follow her to her car and call for help.
Psychiatric nurse Karen Matthews told the court she called Abbie’s friend and family before contacting police at 6.02pm.
Avon and Somerset Police found Abbie in her car in Woolavington and called South Western Ambulance Service.
Before then, Abbie had texted her friend Claudia Dias and spoken to police, refusing to reveal her location and sending goodbye messages.
Ms Marsh recorded a narrative conclusion for Abbie’s death.
She said Abbie died from acute toxicity in the back of an ambulance in Bridgwater on the way to Musgrove Park Hospital at 8.43pm on May 1, 2025.
She said: "Abbie had been located by the police in the community after making disclosures to mental health professionals and her friend about an intention to end her life.
“Abbie had an emotionally unstable personality disorder and a chronic history of suicidal ideation and self-harm.
"On the evidence it is not possible to determine whether she intended to end her life by this act or whether she was simply trying to do enough to get back onto a mental health acute ward where she appeared to prefer to be as this shielded her from the challenges of her everyday life.”
In response to this, Dr Sathya Cherukuri, associate medical director for mental health and learning disabilities at Somerset NHS Foundation Trust, said: “We would like to offer our sincere condolences to Abbie’s family and loved ones at what continues to be an incredibly difficult time.
“We welcome the coroner’s conclusions and will continue to carefully consider the findings of the inquest.
“We remain committed to providing safe, compassionate care for everyone who uses our services.”
When life is difficult, Samaritans are here to listen – day or night, 365 days a year.
You can call them for free on 116 123 or visit samaritans.org.
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