A 55-year-old grandmother with mental health problems locked her family in the house before intentionally driving her car into the path of an oncoming lorry.
Nigel Chapman reported from the inquest at Boston Coroner’s Court for Lincolnshire Reporter on Wednesday, July 3.
Deborah Ann Jackson died at the scene on the A17, near her home in Garnsgate Road, Long Sutton.
Mrs Jackson’s family apologised to the lorry driver for his distress and injuries caused in the crash on November 13 last year.
It happened a day after Mrs Jackson had started an agreed home leave from Peter Hodgkinson Centre at Lincoln County Hospital.
On a previous occasion she had gone missing for two days and was found following appeals in the local press.
Mrs Jackson had been admitted voluntarily last October after her son Adam had caught her trying to hang herself.
The inquest also heard of an incident in which Mrs Jackson looked as though she might step in front of a moving car. She later said that one voice in her head had told her to do it but another had told her not to.
Both incidents were reported to staff but consultant psychiatrist Dr Syed Zaidi, who assessed Mrs Jackson several times, said he could not recall being aware of them.
Assistant coroner for Lincolnshire Paul Cooper put to Dr Zaidi that Mrs Jackson’s family were “begging” for her to be detained.
He replied that she didn’t satisfy the legal requirements and even if he had known about the two serious incidents, it would not have changed his later opinion that her condition had improved and she could go on accompanied home leave.
“She was engaging with activities, her sleep was improving, she was complying with all recommended plans and had capacity so there was no reason for anybody to realise that she needed sectioning,” said Dr Zaidi.
He added: “Risks can never be eliminated, they can only be minimised.”
Lincolnshire Partnership NHS Trust conducted a Serious Incident Investigation Report following Mrs Jackson’s death.
Director of operations Christopher Higgins said: “We couldn’t find anything that was a direct root cause to the incident.”
He added that there were issues surrounding documentation, assessment tools and communication which had either been addressed or were being so.
Mr Jackson told the inquest that his mother was at her best when playing with his young daughter, which she had been doing on the day she died.
“She told us she was off to the toilet. She locked us in the house and drove off,” he added.
Lorry driver Ashley Green, of Huddersfield, was heading east towards Sutton Bridge when Mrs Jackson’s car crossed into his side of the road.
“I illuminated all my headlights, thinking that whoever was in the oncoming car would correct themselves but they were not showing any signs of moving,” Mr Green told the hearing.
As the Renault Clio got closer, Mr Green steered towards the verge but was unable to avoid the collision. Mrs Jackson, who was in pyjamas and not wearing a seatbelt, was thrown from the car. The lorry partially toppled onto its side.
Dashcam footage from the lorry showed that Mrs Jackson had “straightened up” after crossing into the opposite carriageway and had done nothing to avoid the impact.
Forensic collision investigations found that Mr Green had only three seconds to react and he was entirely not to blame. The conclusion was that Mrs Jackson’s action “may have been deliberate”.
Coroner Mr Cooper said he had considered road traffic collision and suicide as a conclusion but the two were “inter-linked” in this case and so he chose to record a narrative conclusion.