Coroner to write letter of concern after patient's death at mental health clinic

A coroner will write a letter of concern to the new operators of a private mental health hospital in Oakley Green, following an inquest into a patient’s death in the clinic's grounds.

Cressida Comyn, 39, was found unresponsive following a fatal act of self-harm in the grounds of the Cardinal Clinic  - ‘less than 50m’ from the main building - around an hour after she went missing at night on August 6, 2024.

At an inquest conclusion on Friday (September 19), coroner Alison McCormick said there was no evidence 'on the balance of probabilities' of problems that had made 'a more than minimal contribution' to her death. 

But Ms McCormick said she would write a letter of concern to the new Cardinal Clinic manager, to request information including its patient admissions policy and exterior CCTV coverage. 

Cardinal Clinic closed in February this year, after its management company Bishops Lodge Limited fell into administration. The clinic has since reopened under a new operator.

Archive image of the Cardinal Clinic in Oakley Green

Cressida, an asset manager from Battersea, was voluntarily admitted to the Cardinal Clinic on August 2 for treatment of symptoms of severe anxiety, paranoia and psychosis.

At night on August 6, Cressida ran away from the Cardinal Clinic. A 999 call came in at 9.50pm, around 20 minutes after she went missing, and emergency services began a search effort.

Police tracker dog Venn found her around at around 10.30pm in an allotment area ‘less than 50m’ from the clinic building itself, the inquest heard.

After 40 minutes of CPR from air ambulance paramedics and specialist support from armed police, Cressida was pronounced dead at 23.11pm.

A toxicology report said she had died from asphyxiation, and Ms McCormick ruled the death as by suspension.

The inquest took place in Reading Coroner's Court in the town hall (pictured)

Questions had been asked about Cressida’s treatment at the clinic and the search for her by the coroner and barrister William Lacey KC, who was representing the Comyn family during the inquest.

The inquest also heard a statement from Cressida’s partner Jamie Collins which said ‘we trusted Cardinal Clinic to look after her’ and she was ‘terribly let down’.

Ms McCormick concluded that ‘on the balance of probabilities’, there were no problems with Cressida’s treatment that had made a ‘more than minimal contribution’ to the death.

She said staff at the clinic had taken ‘appropriate’ measures to reduce Cressida’s risk of self-harm, and the search effort by police after she was reported missing had also been ‘appropriate’.

Cressida was under one-to-one supervision when she fled the clinic. However, Cardinal Clinic is a non-secure clinic, meaning its doors are not always locked.

The inquest heard how doctors did not consider that she met the criteria for being detained under the Mental Health Act, or transfer to another more secure facility. A detention under the act is known as being sectioned.

Ms McCormick said that there was no evidence that ‘on the balance of probabilities’, an assessment under the Act would have saved her life.

But Ms McCormick said she would write a letter of concern to the new registered manager of Cardinal Clinic.

The letter would ask for details of the clinic admissions policy, the availability of methods of communication between staff such as radios, and CCTV coverage around the clinic grounds.

Guidance from the Chief Coroner describes a letter of concern as ‘an exceptional course of action’.

A letter can be written to an organisation or person where there is still concern following an inquest case, although there is not necessarily perceived to be a direct risk of future deaths.

'The shining star ever present in our lives'

Cressida Comyn has been remembered by her friends and family

Cressida’s mother and father Jane and Tim Comyn, and her partner Jamie Collins, were present throughout the five-day inquest proceedings.

Ms McCormick told the inquest: “You gave her your continual love and support; and in this way, you gave her everything that she could and should have expected.

“You did everything that you could. You could have done no more - and that shines through in the [inquest] evidence.

“I hope that this thought, together with the opportunity that you have seized - very bravely, if I may say so - to engage in this inquest will, in the fullness of time, bring you some resolution and peace.”

Hundreds of people attended a memorial service for Cressida in St Mary’s Church, Uffington, following her death.

A statement read at the service by her father Mr Comyn said: “Above all she loved us; all of us.

“And so we shall remember her not as the Cressie we have lost, but as the shining star ever present in our lives.

"Her infectious smile spreading like the sun on her face, forever lighting up our days in proud and joyful recollection of a life well lived.”

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