Daniela Pani deliberately left the platform as a train was approaching in Berkshire last year on June 29.
An inquest held at Berkshire’s Coroners Court on July 4 this year heard that she ‘had suffered from a serious and enduring mental health problem for most of her adult life and was under the care of the mental health services at the time of her death’.
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Coroner Robert Simpson has since written a Preventing Future Deaths report following his concerns about the circumstances surrounding her death including a lack of Samaritan signs at the platform.
During the inquest, it was heard that Daniela has suffered from bi-polar affective disorder for several years prior to her death.
Over the course of 2022, her mental health deteriorated and she then came under the care of the Community Mental Health Team (CMHT) and Crisis Resolution Home Treatment Team (CRHTT) – which are services provided by the Berkshire Healthcare NHS Foundation Trust.
In May 2023, this culminated in her admission, as a voluntary patient, to an in-patient ward at Prospect Park Hospital. Daniela was discharged from Prospect Park Hospital the following month.
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On June 28, 2023, Daniela was due to have a review meeting with a member of the CMHT. However, she cancelled the face-to-face, saying she was unwell.
Instead, the review took place over the phone, during which Daniela denied that she had any intent to harm herself.
Later that day Daniela twice called the CRHTT Crisis Line. She was assessed as not posing an imminent risk to herself.
The following day, she took a taxi to the train station and was struck by a train. Her medical cause of death was a severe head injury.
Coroner Mr Simpson stated that his concerns are about the train station and the CMHT meeting.
In terms of the train station, Mr Simpson expressed concerns about a lack of Samaritan signs as well as the car park fencing being too low.
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With the CMHT meeting, Mr Simpson expressed concerns that ‘training and guidance did not specifically address how to deal with service users declining a visit or meeting’.
He said: “I am concerned that the staff not being able to carry out face-to-face assessments in all possible cases gives rise to the risk of future deaths.”
The report has been sent to Berkshire Healthcare NHS Foundation Trust, British Transport Police and South Western Railways.
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