Chadwell Heath woman Amarnih Lewis-Daniel inquest jury sent out

But they have been told not to find that the actions of police, probation or mental health service North East London NHS Foundation Trust (NELFT) contributed to the death of Amarnih Lewis-Daniel.

Coroner Nadia Persaud gave legal directions to jurors after six days of evidence at Amarnih’s inquest at East London Coroner’s Court in Walthamstow.

She told them they must return one of two conclusions – either suicide, or a narrative conclusion.

They can also provide a written summary of anything they deem “relevant to the direct sequence of events leading to Amarnih’s death.”

Amarnih, 24, was found dead at the foot of Highview House, off of Whalebone Lane in Chadwell Heath, on March 17, 2021.

She is believed to have deliberately set fire to her own flat on the seventh floor.

Although born male, she identified as female from a young age, legally changed her name and had been on a waiting list for the Tavistock gender clinic since summer 2018.

The inquest heard she was known to NELFT, with diagnoses of anxiety, depression, gender dysphoria/incongruence and traits of emotionally unstable personality disorder. She was also awaiting an autism assessment.

Amarnih Lewis-Daniel, 24, was found dead at the foot of Highview House, Chadwell Heath, on March 17, 2021. Above, a fire was burning inside her sevent-floor flat (Image: Google Streetview)

The coroner told jurors that since being sworn in last Monday, November 20, the list of issues they would have to consider had become “much more narrow”, based on evidence heard in court.

For example, jurors have heard about three occasions in the weeks before Amarnih’s death when NELFT staff could have referred her for a mental health assessment.

Expert witness Dr Duncan Harding, a forensic psychiatrist, said on two occasions a referral was “essential” and “urgent” and might have prevented her death.

But, Mrs Persaud pointed out, he was unable to say that it was probable that her life would have been saved.

Jurors must only find that a factor contributed to a death if they find it proved “on the balance of probabilities”.

On that basis, said Mrs Persaud: “There is no evidence before you that a referral to the Access Team at that time would have prevented her death. You cannot therefore lawfully include any reference to that.”

Similarly, she said: “There has been no evidence that any action or inaction on the part of the mental health trust, police, probation or the local authority contributed to her death.”

Jurors in Amarnih Lewis-Daniel’s inquest were sworn in at East London Coroners’ Court, Walthamstow, on November 20 – coincidentally, also the International Transgender Day of Remembrance (Image: Google Streetview)

Mrs Persaud read out a list of issues she felt jurors could reasonably consider.

“What mental health diagnoses and symptoms did Amarnih suffer from?” she said. “Were there any changes in her mental health in 2021?

“She had been on the waiting list for the gender identity clinic since 2018. In your view, did the delay in reviewing this assessment impact upon her mental state?”

Another question, she said, was: “Did she take the action that led to her death, and did she intend to bring about her death at that time?”

“That list of issues are only suggestions,” said Mrs Persaud. “You can include other issues that you consider to be important… What you find and how you express it is entirely a matter for you.”

Mrs Persaud told jurors there were two possible conclusions (formerly known as verdicts): suicide or narrative.

They could only find the former if they were “satisfied, on the balance of probabilities – which means more likely than not – that Amarnih intended to take her own life”.

Otherwise, they could opt for a narrative, which “can include the cause of death and any other factor directly relevant to Amarnih’s death”.

“Your findings must be based solely on the evidence that you have heard and seen in court and nothing else, such as media coverage,” the coroner said.

“This was not a trial. An inquest into a death is a fact-finding inquiry and the inquest has been to find out how Amarnih died. It is not a process concerned with attributing blame.”

Catch up on our exclusive, in-depth coverage of the Amarnih Lewis-Daniel inquest: