An inquest into Michelle Sparman’s death that opened on Monday, 27 January 2025 has concluded at Inner West London Coroner’s Court as of today.
Michelle, a Caribbean woman, tragically died by suicide in August 2021 after attempting to take her own life at Queen Mary’s hospital, where she had been admitted as a voluntary inpatient. Michelle’s family were concerned that she was being subjected to domestic abuse by her ex-partner Roger Stephens in the years before her death. Michelle’s siblings, Shaun Case and Anthea White, invited the inquest to probe into the impact of Roger’s behaviour on Michelle’s mental health and to investigate whether NHS agencies failed to pick up and act on Michelle’s reports of domestic abuse.
In proceedings held between January and November, the inquest heard evidence about the impact of Roger’s relentless messaging on Michelle’s state of mind. Witnesses shared that Roger’s messages, which accused Michelle of having “something wrong with her mentally” for leaving him and of ‘harming’ their children, left Michelle anxious with tightness in her chest. The inquest heard how he undermined Michelle’s confidence and made her feel like a failure. Witnesses added that Roger was also prone to sharing suicidal ideation with Michelle, despite her requests for him to stop. This bombardment of messages, coupled with Roger’s unpredictable behaviour, distressed Michelle. Witnesses noted that in moments she was struggling to cope, Michelle even questioned if it would be easier to return to the relationship, indicating that she had previously stayed due to these very concerns.
The inquest also heard evidence of Michelle’s self-referral to Talk Wandsworth and of the Cognitive Behavioural Therapy she received between 2020-2021. The witness shared that Michelle had communicated Roger’s “narcissistic”, “blame-shifting”, and “controlling” traits to them and discussed his frequent attempts to berate and guilt her for her decision to end their relationship. The witness added that though Michelle wasn’t treated as a victim of domestic abuse at the time due to having already left the relationship, it is now undeniable that Michelle was vulnerable and experiencing domestic abuse. The witness admitted that Michelle would have benefitted from referral to a specialist domestic abuse service.
During their witness statements, the psychiatrist and manager at Rose Ward at Queen Mary’s hospital raised concerns about Michelle being subjected to domestic abuse too. This was partly due to the information on Roger’s behaviour shared by Michelle or her family and partly due to Roger’s agitated state during a hospital visit. The question of whether Michelle’s risk assessment could have been bolstered through measures such as access to Talk Wandsworth records lingered.
The inquest recorded a finding of death by suicide due to Michelle’s mental state contributed to by neglect on the part of the NHS psychiatric ward. The Assistant Coroner identified Michelle’s relationship with Roger as ‘difficult’ with ‘toxicity’ in it and recorded it as a key causative factor. In particular, he noted that Roger’s ‘intemperate and excessive texting’ called into question Michelle’s mental health and fitness to be a mother and affirmed Michelle’s feeling of being abused as ‘justifiable’. In relation to neglect, the Assistant Coroner stated that she should never have been put in a position where she could cause harm to herself. The NHS psychiatric ward’s failure to adequately search for any harmful objects in her possession was found to be the failure of a fundamental obligation amounting to neglect.
In response to the inquest verdict, Michelle’s siblings, Shaun Case and Anthea White, said:
“We knew for a long time that things weren’t right between Michelle and Roger, but it was only in January 2020, when Michelle announced that she was ending her 26 year relationship, that she told us how unhappy she had been for years and began to share recordings and text messages she was receiving from Roger.
These fell into 3 categories:
Although Michelle knew the messages were to bully and coerce her into taking him back, they still affected her. Roger’s relentless accusations of ruining his life and those of the boys, made her anxious. She lost sleep, her appetite, her confidence and her motivation and energy. As she deteriorated she became more vulnerable and began to believe that she was the problem. That she had failed her boys, and that everyone would be better off without her.
The response from the police has been utterly appalling. From the outset we were told they don’t usually investigate suicides and there was no case as Michelle had not reported domestic abuse when she was alive. It is therefore a huge relief that the abuse Michelle experienced has been recognised as a significant factor in her decision to end her life.
I would like to thank Southall Black Sisters for their support, and Hogan Lovells and our legal team for representing us. And a special thanks to our AAFDA caseworker who has been guiding and supporting us throughout the last 4 years.”
Reacting to the inquest verdict, Hannana Siddiqui, Director of Policy, Campaigns and Research at Southall Black Sisters said:
“We welcome the Assistant Coroner’s recognition that Michelle’s suicide resulted from a state of mind in which she felt she was being subjected to domestic abuse and due to neglect from the NHS psychiatric ward. This is a landmark decision as it is one of a handful of cases in which the link between suicide and domestic abuse has been explicitly recognised, especially in relation to a Black, minoritised, and migrant woman. We believe it will aid in preventing suicides and in holding perpetrators to account.
The police had previously failed to investigate Michelle’s death as a possible criminal offence, and we now call on them and the Crown Prosecution Service to review the case.
As a frontline organisation, we know that this is a pattern of statutory failures. Black, minoritised, and migrant women disproportionately bear the burden of these failures given the heightened risks of suicide and the additional barriers to accessing support. Urgent reform is needed to prevent against the tragic loss of lives due to domestic abuse and other forms of violence against women and girls.
Legal recognition of suicides aggravated by domestic abuse as murder and the introduction of statutory best practice guidance for agencies, including the police and Crown Prosecution Service, health and social care, and the Coroners’ Courts in dealing with such cases is a vital first step. Specialist ‘by and for’ services also need to be fully funded in order to provide crucial support to victim-survivors and bereaved families. We call on the government to introduce these measure to prevent suicides in its forthcoming national strategy on violence against women and girls; and to accept our amendment to the Crime and Policing Bill. We also call for an independent public inquiry on femicide. Urgent action will ensure that Michelle’s death was not in vain.”
Assistant Coroner Bernard Richmond KC led the inquest. Michelle’s family were represented pro bono by Hogan Lovells International LLP and Jennifer MacLeod and Jagoda Klimowicz of Brick Court Chambers. They were also supported by Southall Black Sisters and Advocacy After Fatal Domestic Abuse.