Kirsty was diagnosed with both a learning disability and mental health conditions (EUPD and ADHD). The Coroner highlighted a lack of provision for LD/MH co-morbidities and a lack of communication between the two disciplines.

In addition: "I remain concerned (as it is a matter I have raised on many occasions at inquest and again as a result of the experiences of the family in this case), that communication with the families of patients with mental health difficulties is still not being effectively achieved. Nor are such families being suffiently, effectively and meaningfuly listened to or understood when they voice concerns, based on their experience of the patient outside of a treatement or assessment environment. Consequently, I am concerned that such matters are not being reflected sufficiently or frequently enough in the onward treatment of those patients or in the clinical curiosity afforded to their conditions.

"There remains an over-focus on patient centric assessments and patient only responses. It is recognised that patients can present quite differently to and in the presence of their families, who know them intimately, to how they may (or may be able to) present to assessing clinicians – with or without the intent to mask their condition.

"Whilst consent to share is an understandable barrier in some cases, there should not be a bar to listening to or to actively encouraging feedback and input from families, especially where a family’s concerns are heightened by any sudden or marked changes in the behaviours, mood or presentation of their relative outside of the clinical/assessment environment – particularly in the case of neurodiversity.

"Unless all concerns are heard and considered and all availble information is taken on board, holistically, there is a continuing risk that the masking of mental health conditions and the deterioration of them may occur or that significant red flags are missed. In this case, the family’s increasingly desperate concerns voiced about their daughter’s evident mental health deterioration in her final days went un-responded."