A 51-year-old victim of an alleged hate crime was failed by Essex Police prior to her death, the county’s coroner has said reports the Local Democracy Reporter.
Aminata Coulibaly was under the care of the crisis mental health team at EPUT linked to a matter that was being investigated as a hate crime around racial abuse, coroner Sonia Hayes has said in a prevention of future deaths report.
She added Essex Police had failed to record important information reported by the mental health trust that Aminata Coulibaly had suffered assault and racial abuse.
They had also incorrectly told Ms Coulibaly that they had closed the case – causing Aminata to suffer significant distress, including suicidal thoughts, anxiety and depression, Ms Hayes added.
She died from acute alcohol toxicity at her home in Tiptree between Friday, June 24 2022, and the morning of Saturday, June 25 2022, but her death was not a deliberate act initiated by herself to end her own life, the coroner said.
A statement said: “The victim’s code was not adhered to by Essex Police. Ms Coulibaly was informed incorrectly that the case was closed by Essex Police.
“The following is a failing by Essex Partnership University NHS Trust, which is a probable cause of Ms Coulibaly’s death; Inadequate case management and lack of recorded background information around next of kin and known friends, lack of continuity in carers and consideration of individual risk.”
The coroner added that Ms Coulibaly made “a very distressed phone call” to the officer in charge of the case on June 24, 2022, but this was not placed on the case management system or shared with the mental health trust.
On June 26, 2022, the mental health trust called Essex Police, reporting concerns for Ms Coulibaly’s welfare.
The mental health trust had texted Ms Coulibaly to say that if they did not hear from her by 5pm then they would contact the police for a welfare check.
On June 26, 2022, a different Essex Police contact handler contacted the mental health Trust to update them on the outcome of their concern for welfare that the police would not attend, as it did not meet the criteria.”
“We have not waited until the publication of this report to identify learnings from the circumstances leading up to her death and implement them.
“This includes placing considerable resource, training, guidance and governance around investigations as well as strict adherence to the victims’ code of practice.
“In line with the coroner’s request, we will of course provide a detailed response to her by January 26, 2026.”
Paul Scott, Chief Executive of Essex Partnership University NHS Foundation Trust (EPUT), said: “I offer my condolences to all who knew and loved Aminata and apologise for the failings in her care at a time when she needed us most.”
