A young woman died after a series of “missed opportunities” by social services and other agencies, a coroner has ruled.

Ayeisha Coates Mohammed was found dead at the age of 20 on Radcliffe Road, The Haulgh on February 13 2021.

An inquest into her death found that her mental health deteriorated in late 2020 and early 2021 but that efforts to help her were limited by the Covid pandemic and the strain on services.

A report by area coroner Peter Sigee said: “The individuals who interacted with Ayeisha during this period had not been provided with a sufficiently detailed picture of Ayeisha to enable them to fully understand and assess her needs and the risks to her at this time and no effective mechanism had been established to enable sufficient communication regarding Ayeisha between relevant professionals.”

Ayeisha had been adopted in 2004 after being removed from the care of her biological mother in 2003.

The hearing was held at Bolton Coroners Court (Image: Newsquest)

Mr Sigee’s report said it was later deemed necessary to return her to the care of children’s services in Oldham but this did not entail any criticism of or failing by her adopted family.

Instead, he said that they “continued to love, care for and support Ayeisha.”

The inquest, that began in May 2022 before recommencing in June this year heard how Ayeisha had been known to have complex mental health conditions.

She was also known to have complex social care and housing needs.

The inquest heard how on December 29 2020 Ayeisha had told a housing support worker that she had been feeling suicidal but was unable to secure a same day appointment with a GP.

On February 4 the following year she told her GP in a telephone conversation that she had been in a “low mood” and said she had made a noose five days earlier but had not used it.

Just days later on February 10 she told a mental health nurse in another telephone conversation that she had “wanted to kill herself but her body wouldn’t let her.”

Three days later she was found dead.

Mr Sigee’s report found that there was a lack of “effective coordination” by the After Care team within children’s social services with responsibility for Ayeisha.

He also found that there was a lack of effective handover from children’s social services to adult social services or adult safeguarding services.

There was also a lack of an effective transfer of information when Ayeisha moved from Oldham to Bolton in March 2020.

Mr Sigee also found a lack of effective information gathering and sharing between professionals, and of sufficient “professional curiosity” by those who were involved in Ayeisha’s care.

There was also a lack of sufficient oversight of the professionals involved by their managers.

Mr Sigee’s report said: “This resulted in missed opportunities to recognise the extent of the deterioration in Ayeisha’s mental state and to offer additional assessment, care and support to her in early 2021.”

But Mr Sigee’s report also said that “on the balance of probabilities” Ayeisha would not have satisfied the criteria to be detained for treatment without her consent.

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He also said that it could not be determined if she would have accepted any additional assessments, treatment or care or if this would have avoided her death.

Mr Sigee’s report said: “Accordingly, it cannot be determined if these failures were causative of Ayeisha’s death.”

He concluded that Ayeisha’s death was caused by “deliberate self-suspension from a ligature.

But Mr Sigee’s conclusion said that he could not determine if she had the “necessary capacity at the time to enable her to form the intention to end her own life.