In January 2014, a 41 year old woman, known only as Ms D to protect her identity, took her third overdose in a matter of weeks which tragically ended her life.

Ms D was, at the time of her death, a community mental health patient and had spent the months before her death asking for more support as she started a new form of therapy.

The therapy was known to be destabilising yet Ms D's regular psychiatric appointments were with a series of locum doctors. Ms D found that different locums could not provide the support she needed as most of the appointment time was used up going over her history. 

Her fiancée wrote to the community mental health team (CMHT) asking for more support and setting out how close they were to not coping due to Ms D's declining mental health.

Ms D's GP also wrote to the CMHT asking for an urgent assessment by the responsible Consultant. 

At the time Ms D died, these letters remained unanswered. The Inquest heard that the responsible Consultant was not even aware of these requests until after Ms D died.

Ms D had reported her escalating self-harming behaviour to the CMHT’s crisis team, and told her family of her disappointment in the lack of support she felt she had received.

After her death, Ms D's family learnt there may have been services that could have been offered such as home visits and emergency appointments.

Ms D's family firmly believed that had Ms D's requests for more help been listened to and the concerns of her partner and GP acted on, Ms D would not have died when she did.

The family instructed Leigh Day to assist them with their efforts to ensure steps were taken by the Trust to minimise someone else falling through the same gaps.

Prior to the Inquest the responsible NHS Trust admitted it had failed to provide Ms D with a reasonable standard of care and that had they done so, Ms D would probably not have died in the way she did.

Following this admission, a claim was settled on behalf of Ms D's Estate and her close family.

Leigh Day also met with the Trust to discuss changes to their practices which should lower the possibility of someone else receiving substandard care. The changes/actions implemented included:

  • creation of 4 new Consultant posts in the responsible Trusts’ CMHTs to provide senior, experienced input into the crisis team;
  • ensuring CMHT patients are told in advance as far as possible if their doctor is leaving the team;
  • undertaking a feedback survey for patients seen in CMHT outpatient clinics; and
  • reviewing and amending CMHT Operational Policy to be clearer regarding who is entitled to on-going care management and to ensure concerns originating from outpatient clinics or calls to the crisis team are discussed with the responsible Consultant Psychiatrist.

At the Inquest however, the Coroner did not find Miss D's death to have been contributed to by the Trust's failure.

Merry Varney, Partner in the Human Rights Department at Leigh Day, who was instructed by the family said:

'The family's actions in response to their loved one's death have undoubtedly lead to improved and safer services for community mental health patients in the area.

“The fact the Coroner appeared to not appreciate the impact on Ms D of the unanswered complaints and lack of continuity of her care, even though the Trust themselves did, was disappointing and highlights the difficulties faced by bereaved families in Coroners Courts.

“In this instance the family were represented and we were able to use other legal avenues to secure recognition of the lack of care Ms D received.

“Across the country many families are unrepresented in Inquests, for a multitude of reasons and in many deaths of mental health patients reports suggest no inquests (or no proper inquests) are even held. This must be urgently addressed as opportunities to improve are being missed.”

Ms D’s family said:

“It would have been marvellous for the whole mental health community if the Coroner had recognised the failings in his Conclusion and if the changes made locally had been seen as necessary to prevent other future deaths in similar circumstances.

“Having legal representation ensured that those responsible for the failings in the system had to face up to what had occurred and consider very seriously what went wrong and what they could have done better. There is no doubt that very important improvements have been made, which we feel we may not have been achieved without instructing Leigh Day who supported us through this traumatic experience in a professional, sensitive and, most of all, human way.”