Our Public Law team have recently supported the family of Danielle Cornish at the inquest into her death. The inquest was heard before HM Area Coroner for South Wales Central, Mrs Patricia Morgan, from 5 to 8 May 2026 and revealed systemic failures by Cardiff & Vale Health Board, with Danielle’s family now calling for urgent changes.
The background:
During 2022, Danielle Cornish’s mental health took a turn for the worse, and multiple times she asked the Health Board for more support.
The inquest examined Danielle’s care and the decisions taken in the days before her death. On Friday 19 August 2022, Danielle told mental health clinicians that she had a lethal substance at home and planned to take it on the Sunday as she would be alone for two weeks from the Saturday. Nurses from the Health Board gave her some Diazepam and told her she would receive a phone call the following Monday (the day after she had intended to take her own life). No crisis or home treatment team support over that weekend was put in place. She called an ambulance on the Saturday evening as she was feeling suicidal, and she attended A&E on the Sunday morning where she was assessed, and still nothing was put in place. She was discharged home and took her own life the following day. The Health Board did not inform her boyfriend of the risks or take any steps to arrange someone to be with her, or for the lethal substance to be removed. Had they done so, her boyfriend would have put plans in place to keep Danielle safe.
The inquest:
The Coroner held that the Health Board missed opportunities, and that the lack of measures to respond appropriately to the risk that Danielle posed to herself contributed to her death.
Danielle’s family are dismayed by the poor quality of care given to Danielle by Registered Mental Health Nurses employed by the Health Board, and the sloppy and laid-back nature of the evidence they gave in court. Most shocking, given the evidence of Danielle being passed repeatedly between services without consistent, long-term support, is that the key Nurse said she would make the same decisions again. It appears that lessons have not yet been learned. The family are shocked that nearly four years on from Danielle’s death, the Health Board’s new policy on dealing with lethal substances is still in draft form. The Coroner has directed the Health Board and South Wales Police to provide evidence on progress in finalising the joint policy within 14 days and will consider issuing a prevention of future deaths report.
Lessons to be learned:
The family are devastated that Danielle felt she had nowhere left to turn. They are also determined that lessons are learned. They call on the Health Board and NHS Wales to:
- Develop a clear, Wales wide protocol to remove or neutralise access to lethal means where a person with mental health problems discloses possession and suicidal intent, with practical pathways that balance the need to respect capacitous decisions to keep information confidential, while acting to prevent imminent harm, and prioritising life;
- Develop a coherent, 7-day per week community mental health service that avoids service silos, and permits people like Danielle to fall between the gap of “long-term” care and “crisis care”, and which guarantees crisis support and face to face contact during times of acute risk, including weekends and when individuals will be alone.
- Increase the competence of staff to properly assess suicidal risk and develop risk formulation plans.
- Ensure a single accountable clinical lead and continuity of care across services, so patients are not passed between teams without ownership.
- Ensure robust record keeping and timely information sharing with families and partners, with patient centred consent discussions and clear criteria for sharing where risk escalates.
- Provide targeted training across NHS Wales on recognition and management of highly lethal methods and on evidence-based suicide mitigation, with rapid escalation pathways.
These changes are achievable and urgent.
Craig Court, solicitor for the family: “This inquest has been an essential process. It has shone a clear light on systemic gaps in assessment, record keeping and weekend safeguarding, and on the need for practical, proactive steps when highly lethal means are known. The family have shown remarkable strength and dignity throughout. Their determination has been focused and they want to ensure that lessons are learned and that future deaths are prevented.”
Remembering Danielle.
Danielle’s family paid tribute to her: “Danielle was the most intelligent, ambitious, beautiful, witty, courageous and driven young woman, of whom we are deeply proud. A cherished daughter, sister, niece, girlfriend and friend, Danielle worked for the Office for National Statistics and was especially proud of her contribution to mortality statistics during the Covid pandemic. Danielle was a born organiser and go-getter who filled life with adventure, whether she was planning trips abroad, baking incredible birthday cakes, cooking fabulous meals, discovering new walks, attending music concerts, or losing herself in countless books with her beloved rescue cat, Travis, by her side. She kept us all in check with her bluntly honest one-liners and wicked sense of humour. Danielle gave us 29 years of amazing, fun-filled memories and achieved so much in her short life, but she still had so much to offer the world. We talk about Danielle daily and will continue to do so for the rest of our lives. The pain of losing her is something we carry every second of every day.
It’s been nearly four years since Danielle took her life and our lives changed forever. Danielle did everything asked of her. She reached out for help and set out exactly what she feared would happen if she was left alone. We will always wonder what might have been different if firm safeguards had been put in place that weekend. Now we ask Welsh Government and NHS Wales to deliver the changes needed so that other families are not left to endure what we live with every day.
We are grateful to the Coroner for her careful investigation of the facts, the way she approached the complex evidence and how she treated us with kindness and respect. We would also like to pay thanks to our legal team for their support and guidance throughout this process.”
Danielle said shortly before her death: “We tell people to reach out when they need help, but when they do (and it’s a fucking difficult thing to do), we push them away or gaslight them into thinking they don’t need it.” Her family hope her story will drive meaningful reform.
Danielle had bought a lethal chemical from the Canadian man Kenneth Law who is being prosecuted for multiple counts of aiding suicide in Ontario, and who is suspected of having facilitated the deaths of around 100 people in the UK. The family also call on the National Crime Agency to do all in their power to ensure that Kenneth Law is brought to justice and prosecuted in the UK.
Craig Court, Partner and Head of Public Law at Harding Evans Solicitors instructed Oliver Lewis of Doughty Street Chambers.
Help is available:
If you are struggling, please reach out to someone you trust or a support service. One service Danielle found helpful and non-judgmental was Samaritans: 116 123.
Do you need inquest representation?
At Harding Evans we recognise how difficult and traumatic the entire inquest process can be for the families and loved ones. We aim to alleviate the process as much as possible and can support you throughout.
If you are seeking legal representation for an inquest into the death of a loved one in England or Wales, please get in touch to discuss your matter.
