Inquest finds disjointed care and poor coordination between care providers contributed to Nottinghamshire woman's death at 22

The inquest at Nottinghamshire Coroner’s Court found that Beth, pictured, died by suicide on 18 February 2023 at Oakwell House, in Retford, Nottinghamshire from the effects of a poisonous chemical. Beth had received ongoing care and treatment for her mental health from a young age, including a number of periods where she was detained under the Mental Health Act.
 
Area Coroner Laurinda Bower found that poor inter-agency working between Nottinghamshire County Council, Nottingham Healthcare NHS Trust, accommodation provider Creative Care and Beth’s clinical psychologist at Oakwell House led to misunderstandings and a disjointed package of care. This led to Beth feeling that she was a burden to those supporting her, and that they did not wish to help her, which contributed to her decision to take her own life on 18 February 2023.
 
Recording death by suicide, the coroner found that those involved in caring for Beth were aware she had a personality disorder and should have known she would be particularly sensitive to feelings of rejection and abandonment because of these failings.
 
Beth had lived in Oakwell House, a supported living placement which specialised in caring for young women with Emotionally Unstable Personality Disorder (EUPD), since July 2021. While living there, Beth also received input from a number of other bodies and agencies, including Nottinghamshire Healthcare NHS Trust, Nottinghamshire County Council, and other support services. Beth initially received 24-hour-a-day one-to-one care from support workers at Oakwell House and struggled with frequent instances of self-harm.
 
Throughout her time at Oakwell House, Beth received input from a clinical psychologist, Gillian Merrill, who was contracted by the facility. However, the coroner heard evidence that Oakwell and Ms Merrill, did not have any kind of written contract or terms of reference which set out what her role was or what she would provide to Beth. Ms Merrill told the inquest that she did not prepare any formalised risk assessments or care plans, did not keep any clinical records of her work with Beth, and did not keep any records of her receiving clinical supervision for her work with Beth. The coroner found that the fluid nature of this agreement and service created significant misunderstandings across the agencies involved in Beth’s care. These included:
 
In April/May 2022, Beth’s family raised their severe concern about the decision by Nottinghamshire NHS Trust’s mental health team to discharge her for the first time in over a decade. The coroner heard evidence the decision was taken in large part as a result of a mistaken understanding about Ms Merrill’s role and the psychological services she provided to Beth. Beth is documented as having herself informed the mental health team at the time that she was not receiving the support they understood she would be, something which her care coordinator admitted at the inquest should have led to a reconsideration of her discharge. Further, the coroner also found that the discharge decision was not carefully considered, planned or structured, and was instead dropped on Beth and other professionals – there should have been a period of observation and support with a view to only discharging Beth if she remained stable. The coroner found that Beth was likely to feel abandoned or rejected by this decision.
 
Through spring/summer of 2022 Beth attended trauma therapy counselling sessions with a local charity. However, in August Beth stopped these sessions and explained this was because Ms Merrill had offered to provide trauma therapy at Oakwell House instead. Despite this and contemporaneous records from Oakwell noting a plan for trauma therapy to be delivered by Ms Merrill, none ever took place. In December 2022 Beth wrote a note which recorded she felt tricked by Ms Merrill and Oakwell’s manager to stop trauma therapy. At the inquest Ms Merrill denied that she had ever offered to provide trauma therapy to Beth, however the coroner found that it was “abundantly clear” from contemporaneous records that Beth had been offered some form of new therapy for Ms Merrill to conduct, which did not take place.
 
From summer 2022 onwards the mental health team continued to make decisions based on a misunderstanding of what psychological services were provided by Ms Merrill at Oakwell House, which included in December 2022 when the mental health team indicated they would not accept Beth back into their caseload because of the support they understood to be offered by Oakwell. This indication was offered without speaking to Beth about the support she was receiving. Beth’s family believe that the decision not to accept Beth back on to the mental health team’s case load was a significant factor in her deteriorating mental health.
 
In January 2023 all one-to-one care at Oakwell was removed at Beth’s request, with Beth then remaining subject to ‘background’ staffing only. This reduction in support was agreed by Beth’s social worker. The coroner found that this decision was made in isolation, without an understanding of what services were being offered to Beth at the time. The coroner heard evidence that Oakwell support staff themselves had concerns this decision was made too quickly and that Beth was not ready for the reduction in support.
 
In early February, Beth unilaterally stopped taking her prescribed anti depressants. The inquest heard how Oakwell staff, despite being aware of the potential for side effects with the sudden cessation of medication, failed to follow their own policy and report this development to Beth’s GP.
 
Following Beth’s death, examination of her mobile phone by police revealed evidence of searches for suicide and self-harm methods.
 
The coroner has issued a Prevention of Future Death report which sets out her concerns about:

• The continued availability of the poisonous chemical
• The lack of awareness among suppliers of the chemical about its use in suicide
• The continued availability of harmful advice about this chemical 

The PFD was issued to two government departments who the coroner believes have the power to address these risks: the Department of Health and Social Care and the Department of Science of Innovation and Technology.
 
Beth’s family describe her as deeply missed for her generosity, courage and extraordinary spirit, often in the face of some very difficult times. She was very creative and enjoyed writing poetry, reading, cooking and baking, and had a wonderful sense of humour.
 
Merry Varney and Caleb Bawdon, solicitors at law firm Leigh Day, and Tayyiba Bajwa from Doughty Street Chambers represent Beth’s family.
 
Shelley Macpherson, Beth’s mother, said:
 
“The coroner’s findings highlight many failings and issues in Beth’s care. We are unequivocal in our view that these issues caused her death. We firmly believe that had she received the support she needed, and that we and Beth repeatedly asked for, she would still be alive today. We hope that the inquest and coroner’s conclusion lead to lessons being learned so that no other family has to experience what we have.” 
 
Caleb Bawdon, a solicitor in Leigh Day’s Human Rights team said:
 
“The coroner’s conclusion comes as a result of the determination of Beth’s family to highlight the issues which led to her death. The coroner’s findings reflect what Beth’s family sadly already knew – that she was badly let down by services and professionals charged with her care. Despite the family’s repeated efforts to raise concerns while Beth was alive, multiple agencies and individuals failed to coordinate and put in place the support she needed. This meant that in early 2023 Beth found herself discharged from the local mental health team, receiving no psychological treatment or therapy, and no longer subject to any kind of one-to-one care by support workers. This significant reduction in support led to Beth feeling abandoned and rejected, and would not have happened had Beth and her family been listened to.”

Beth pictured as a child