Shahzadi, from Manchester, had been sectioned under the MHA and had been in a private MHU in Norfolk. Her family were unable to visit, leading to Shahzadi feeling isolated and clinicians not being able to have the family's input to her treatment.

There were significant communication failures at the time of Shahzadi's discharge, leading to a failure to provide s.117 after-care and placement on the wrong clinical pathway. In the absence of the right care and support, Shahzadi took a fatal overdose.