Forensic psychiatrist Duncan Harding told jurors at an inquest that Amarnih Lewis-Daniel had been “bouncing between services” at a London mental health trust.
“When I tried to unpick this case I found it very difficult,” he said. “It would have been impossible at the time.”
A lack of “joined-up thinking” meant nobody seemed to recognise that Amarnih was “a person potentially in crisis”, he claimed.
If staff had not missed “urgent” and “essential” opportunities to refer her for mental health assessments, he said, it was “possible” Amarnih’s death “could have been avoided”.
Amarnih, originally from Walthamstow, was found dead at the foot of Highview House, the Chadwell Heath tower block where she lived, on March 17, 2021.
Jurors have heard how a series of arrests and parole breaches brought her to the attention of official agencies in the weeks before she died, but none made a mental health referral.
Two major incidents came almost immediately after Amarnih received communication from mental health trust North East London NHS Foundation Trust (NELFT).
Dr Harding, who has no link to NELFT, told East London Coroner’s Court on Monday (November 27) that he felt these approaches had likely left Amarnih “distressed”.
However, he could not say they had caused her subsequent behaviour.
The court was told that on January 29, 2021, Amarnih was sent a text message informing her of a plan to assess her for autism over a video link, rather than face-to-face, due to the ongoing Covid-19 pandemic.
The inquest had already heard evidence that Amarnih was uncomfortable with video calls, possibly because she was transgender and self-conscious about her appearance.
Less than an hour after receiving this text message, Amarnih barricaded herself in her flat, smashed the windows and began “throwing furniture” down onto parked cars, the inquest has been told.
The court heard a mental health nurse employed by NELFT visited Amarnih in police custody that afternoon and reported that she would not cooperate with a mental health assessment.
He looked Amarnih up and found she was known to NELFT, diagnosed with anxiety, depression and traits of emotionally unstable personality disorder.
He logged the January 29 incident on a database but did not make a referral for a new mental health assessment, which Dr Harding said would have been “good practice”.
Days later, Amarnih’s mother called NELFT’s autism assessment team and expressed concern that her mental health was deteriorating. She specifically cited the January 29 arrest, the court heard.
Amarnih’s mother was “reassured” that other services were looking into the situation. In fact, they were not.
“I don’t think that’s acceptable,” Dr Harding said.
Dr Harding said neither Amarnih’s risk-assessment nor her case plan were updated in response to the January 29 incident or her mother’s phone call.
“She should have been referred,” he said. “It’s not just good practice at that moment. It’s essential practice.
“I think it should have been very urgent for the service to get a handle on what was happening to this person. [There’s] risk to self and risk to others. She could have killed someone when she threw things out of the window. It’s a big deal.”
He described Amarnih’s condition as indicative of “a severe risk”.
On March 6, Amarnih was arrested at her mother’s house after showing up uninvited and refusing to leave.
The inquest heard she kicked police officers in their chests and stomachs as they tried to detain her and a kitchen knife was later found in the room where she had been arrested.
She was seen by another custody nurse, who again wrote on a database that she refused to engage with him, but made no referral.
Dr Harding said this constituted a second “essential” missed opportunity.
In court two days later, Amarnih’s behaviour was so erratic that magistrates ordered an assessment under the Mental Health Act – but it was cancelled after she calmed down. She was released on bail.
NELFT was not informed of this.
“Being a practitioner on the ground, I wouldn’t have known about it,” said Dr Harding.
The court heard that on March 17, Amarnih was contacted by NELFT again about a video call for an autism assessment.
Hours later, emergency services were called to a fire in her flat and found her body in the car park outside.
The inquest continues.
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