Date published: 15th January 2021

Coroner finds teenager Charlotte Franklin died due to consequences of Body Dysmorphic Disease and had become ‘overwhelmed with the prospect of not being able to be well’ before her death, in narrative conclusion.

Friday 11 & Monday 14 December 2020

London (North) Coroners Court

Before Senior Coroner Andrew Walker Esq.

Counsel – Emma Favata, Garden Court Chambers

In a narrative conclusion, HM Coroner found:

On the 11 September 2019, Charlotte May Franklin was found having hanged herself using a length of rope over the bathroom door in her bedroom at her home.

Charlotte suffered with Body Dysmorphic Disorder and as a consequence a form of Obsessive Compulsive disorder. Charlotte was highly intelligent, insightful, deeply complex and articulate.

Charlotte engaged in behaviours including excessive washing, checking mirrors, rituals associated with washing and other cleanliness rituals.

There were features, including impulsivity, emotional outbursts, constant suicidal ideation together frequent and serious attempts at self-harm which were likely in response to Charlotte’s concerns around her Body Dysmorphic Disorder and, additionally, in response to interpersonal conflicts that arose during episodes of treatment. This, together with behaviour associated with her unhappiness, is likely to have led to a diagnosis of Unstable Personality Disorder.

During the many admissions and interventions, this type of behaviour, although in part the result of her condition, may have become a tool to ensure that the care that she felt she needed to treat the conditions she knew she was suffering from. At one point recognising that in order to be allowed to leave hospital the self-harm behaviour would need to stop and so it stopped.

Although inpatient treatment was necessary to keep Charlotte safe it did not resolve the underlying Body Dysmorphic Disease and the emphasis was always on treating the Unstable Personality Disorder. The best treatment option, and the one that Charlotte wanted, was treatment at home for the Body Dysmorphic Disorder. Charlotte was discharged into the community on the 2 May 2019 and was treated at home.

Charlotte wrote in the notes found after her death that “I am so tired; I am so exhausted from all this pain and suffering and I can’t hold on anymore I have fought for 5 years and I’ve got worse and worse and it’s broken me”.

Charlotte had never failed to complete her routines but did so for the first time the evening before she died. It is likely that Charlotte had become overwhelmed with the prospect of not being able to be well.

All Charlotte ever wanted was to be normal.

Charlotte was a deeply loved sister and daughter who tragically died aged nineteen years on the 11 September 2019 at home.  

Charlotte had been treated under the Mental Health Act on a number of occasions from the age of 15. She was under the care of Hertfordshire Trust when she was transferred as an inpatient to Adult Mental Health Services on her 18th birthday. Charlotte remained under the care of Hertfordshire Trust in a number of different units, including a unit for the treatment of adults suffering with Emotionally Unstable Personality Disorder, until her discharge home on 2 May 2019. Charlotte suffered with Body Dysmorphic Disorder, and as a consequence a form of Obsessive Compulsive Disorder.

On 2 May 2019 and until her death, Charlotte was under the care of Borehamwood Adult Community Mental Health Services.

“Of Mice and Men” was one of her Charlotte’s favourite books and her family note that the story is about friendship, loneliness, violence, justice and a continuous fight to survive which is exactly what Charlotte was experiencing through the last few years of her life.

Charlotte’s family are devastated by their loss but grateful to the Coroner for the thorough investigation and conclusions found.

The family hope that the Coroner’s finding that it was unsafe to conclude that Charlotte had committed suicide will increase public awareness of how those suffering from Body Dysmorphic Disorder can be driven to end their lives through despair and hopelessness despite a desire to live and be normal.

Emily Comer, solicitor for the family noted that this was an important conclusion in recognising the issues surrounding the diagnosis and treatment for Emotionally Unstable Personality Disorder when a patient is suffering from Body Dysmorphic Disorder. Mind, the mental health charity has noted that specialists often disagree about how to understand personality disorder.

The family is represented by INQUEST Lawyers Group members Emily Comer and Erin Watkinson from Broudie Jackson Canter Solicitors and Emma Favata from Garden Court Chambers.