Family’s Lawyers Want NHS Trust To Learn Lessons After Inquest

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Coroner: Dr Julian Morris at Southwark Coroner’s Court.

Lawyers acting on behalf of the family of a woman found dead in her supported living apartment have today called for the NHS Trust responsible for her care to provide reassurance that lessons have been learnt after a Coroner returned an open conclusion.

During an inquest into the death of the woman, referred to here only as Ms T at the family’s request, Coroner Dr Julian Morris heard that she had a history of mental health problems, for which she had been under the care of the South London and Maudsley NHS Foundation Trust’s (SLAM) Community Mental Health Team.

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Ms T had a diagnosis of schizophrenia and received what was known as ‘floating support’ from carers, she was well known to the CMHT for being non-compliant with her anti-psychotic medication, which she needed to take for her mental wellbeing.

Despite this, a catalogue of errors over a number of months saw mental health care workers fail to respond to well-documented signs that her mental health was deteriorating, and fail to check on her after she threatened to refuse to take her medication.

Ms T tragically died alone in her unheated flat – where she was found lying on a bare mattress in the living room, wearing only a white top, with no food in the flat - sometime between 4th and 6th December 2017, when she was discovered by police, after being reported missing by her care coordinator. 

At the time of her death the cause was recorded as ‘unascertained’ – meaning there was no medically known reason for how she died - and yet her family have been forced to wait more than 3 years for the inquest to take place. A delay their lawyer, Chris Callender from Simpson Millar, says has resulted in an ‘agonising wait’ for answers.

A leading public law expert who specialises in supporting families during the inquest process, Chris said: “Ms T’s son has now had an agonising wait for more than three and half years for an inquest to take place, during which time they have been none-the-wiser as to the cause of her death or the circumstances surrounding it.

“During the 3 day inquest some deeply disturbing evidence came to light about the level of care that she received in her final months and days, and it is clear that more could have been done to prevent her death.”

Despite the period of time that passed between the various pieces of important and significant evidence were only disclosed throughout the three day Inquest hearing – including addendum report by Ms T's psychiatrist, Dr Alyas, which was disclosed by SLAM the evening before the inquest began.

The London Borough of Southwark, who attended the inquest in the capacity of an 'interested person', also only disclosed Ms T's adult social care records on the second day  of the inquest.  The Metropolitan Police Service were another 'interested person'.

Chris represented the family of Ms T at the inquest, alongside Oliver Lewis of Doughty Street Chambers, added: “The family are shocked and appalled by the lack of record keeping, care planning, communication, or organisation shown by Ms T’s care coordinator and consultant psychiatrist.

“Our client has suffered immeasurably as a result of these failings."

  • "While it is reported that there have been a number of policy changes that have now been implemented as a result of this case, we would urge the Trust to make public the findings of any internal investigations so that those in their care, and their family members, have the reassurance that lessons have been learnt. “Only then will the family of Ms T feel that justice has been done and that others won’t suffer in the way she has moving forward."

    Chris Callender

    Public Law Solicitor

Commenting following the conclusion of the Inquest Ms T’s son, who does not wish to be named, said: “I am not here to pass blame or make anyone uncomfortable as that is the Coroner’s job.  However, listening to the evidence over the last few days has been painful and aggravating.

“The reason I say this is that, in all honesty, the role of some more than others has been frankly embarrassing and inadequate to say the least.

“Basic and simple things that could have been sorted out easily have taken longer than they needed to. I feel there was no collective effort as there should have been in situations like this, where someone’s life was at stake. Ultimately not one of the organisations took responsibility in anyway shape or form for their mistake/s in this process.

“I feel like the structure and partnerships dealing with mentally unwell people need to change to accommodate the fact that people have families, and the aftermath of sudden deaths can traumatically affect those families.

“I was 15 years old at the time this happened and felt that all of the responsibility fell on to my shoulders when it clearly shouldn’t have.

“It is shameful that the organisations involved allowed me (a child) to feel this guilt and blame, when others had obligations to care, support, and look out for my mother."

  • "I cannot change the past but hopefully the present and future care can change for the better as I don’t want anyone else to experience this sad reality. I would like to thank the Coroner for the interest, care, and concern he has shown and the fairness with which he has dealt with the case."


    Ms T's son

Order of events:

At the inquest, the Coroner heard that on 4th October 2017 Ms T agreed to have her anti-psychotic medication administered by depot injection in order to avoid being recalled under a Community Treatment Order to hospital.

On 11th October 2017, the CTO expired due to the psychiatrist failing to extend it. On the same day, Ms T told her care coordinator that she would not take any further depot medication. 

Her care coordinator had given her 14 days of oral medication to take at the time of her injection but did not follow up or check that she had taken this. No updated care plan was in place in respect of Ms T’s care throughout 2017 and no provision was made for her to receive any medication, despite it being known that she would quickly relapse without it.

Ms T’s care coordinator went on leave at the beginning of November 2017.  She did not ensure that there was “an out of office” response on her email account to alert other agencies involved that she was not available. 

There was no record that she handed over Ms T’s care for mental health monitoring to a colleague, and there  was confusion as to whether SLAM had allocated Ms T into a 'red' or 'amber' zone: there was no zoning policy in place and the approach of patients in various zones remained unclear.

Other social workers involved with the family raised concerns that Ms T might be suffering a mental health relapse when she saw her briefly at the beginning of December 2017.  Signs that Ms T’s mental health was deteriorating were well known and included her dressing in all white clothes, only drinking milk, and not engaging with care staff.

Ms T’s care coordinator and consultant psychiatrist attempted to visit Ms T on 4th December 2017 but could not gain access to her property.

They requested the police to do a “welfare check” but were told the police no longer undertook these checks unless there was real and immediate risk to life or limb. Ms T’s care coordinator stated that a welfare check was needed because they had not seen Ms T recently without further elaboration. SLAM did not consider obtaining a warrant under s.135 MHA for police to enter the property.

Two days later, after reporting Ms T as “missing” her care coordinator requested another welfare check which was carried out.  Police gained entry into the unlocked property on 6th December to find Ms T dead in the living room.

An inquest into her death was opened on 3 January 2018. It concluded on Friday, July 2nd, 2021, at Southwark Coroner’s Court.

Coroner Dr Julian Morris concluded that the cause of Ms T’s death was unascertainable and returned an open conclusion.

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