Michelle Sparman Inquest: suicide caused by justifiable feelings of abuse by ex-partner and neglect by NHS Trust

18/11/25

In conclusions given on 17^th November 2025, Bernard Richmond KC, Coroner for Inner West London, found at the end of an inquest started in January 2025 that Michelle Sparman, a beloved mother of two, died by suicide with the balance of her mind disturbed.  He held that she ended her life while in an in-patient facility due to “justifiable feelings of abuse” arising from “intemperate and excessive texting” by her ex-partner, and that there had been a gross failure amounting to neglect on the part of the NHS Trust with whom she was an inpatient.

Michelle Sparman was the mother of two sons and a beloved sister and friend. She was a fitness instructor and the founder of a fitness charity, Fit SW11, which provided free fitness clothing for women.

The Coroner found that Michelle had a history of anxiety and depression. He found that Michelle’s mental health deteriorated after separating from her ex-partner, during a period in which he “bombarded” her with texts which were at times “hurtful”. Michelle had described the relationship as abusive to mental health professionals and to her family and friends. The Coroner found that there was a “toxicity” to this relationship and that these texts created an inability for Michelle to move on with her life and meant that she felt trapped in her difficult situation with him. Michelle was also affected by a number of other stressors, including financial and work difficulties.

After entering in Rose Ward, a psychiatric NHS facility, as voluntary in-patient, Michelle used a belt to end her life on 24 August 2021. It is not known how Michelle gained access to the belt, which was not recorded on Michelle’s property forms. Under her care plan, she was assessed as high risk and not allowed to have any potential ligature items. The Coroner found that in this context, “the failure to search adequately is so fundamental it easily passes the Jamieson test” (the standard of gross failure required for a neglect finding).

The Coroner reached the conclusion that Michelle’s death was a suicide whilst the balance of her mind was disturbed, with neglect by the NHS Trust as a contributing factor. The Coroner recorded the following probable causes on the record of inquest:

1. Michelle’s mental state, anxiety and depression, of which impulsiveness was a factor;
2. Michelle’s difficult relationship with her ex-partner, which included “intemperate and excessive texting” which “called into question inter alia her mental health and her fitness to be a mother”;
3. Michelle’s “justifiable feelings of abuse” arising from that behaviour; and
4. Inadequate property searches by Rose Ward.

The Coroner recognised that Michelle was someone with ambition and drive who was very loved and who gave much love to others, and expressed his condolences.