NHS unfairly burdened Essex family to protect woman before her …
A woman who took her own life after believing she had not slept in years should have had more support from the mental health trust, a coroner has warned. Coroner for Essex Sean Horstead has told Essex Partnership NHS Trust (EPUT) there was an ‘inappropriate over-reliance’ upon Johanne Blackwood's family members, principally her husband and son, to keep her safe in the community.
He said this involved the family monitoring 55-year-old Ms Blackwood 24 hours a day, seven days a week over an extended period and physically preventing her from leaving her home address unaccompanied. This over-reliance “placed an unfair and unsustainable burden on the family”, particularly in the light of a highly concerning text message sent by Ms Blackwood to her care coordinator threatening suicide on June 11, 2021, the day before she took her own life.
Following receipt of the text and seemingly reassured in part by her apparent retraction of the threat later that day, there was a failure to undertake an urgent face to face assessment by the community team to establish whether a referral to the crisis team was necessary, the inquest heard. The coroner has said this specific failure possibly contributed to her subsequent death.
Ms Blackwood took her own life after being struck by a train in Tilbury following a period of severe and long-standing mental health disorders including persistent delusional disorder, mixed anxiety and depressive disorder and panic disorder.
The coroner said that an inappropriate over-reliance upon family members to keep a vulnerable and high-risk person safe in the community, over an extended period, probably contributed to her taking her own life.
A central aspect of Ms Blackwood’s delusional beliefs was that she had not slept for years and that she suffered from a fatal physical health condition.
The desperation caused by her “delusional and medically entirely unfounded beliefs” led to a number of suicide attempts and both voluntary and compulsory admissions to mental health units.
She had attempted to take her own life some five weeks before her death but her community risk assessment, her care plan and her safety plan were not updated since the date of her last discharge as a mental health in-patient on December 18, 2020. She did not have an allocated care coordinator for several weeks up to the beginning of May 2021.
The coroner in his prevention of future deaths report submitted to EPUT said: "Whilst her high risk of suicide was acknowledged by the community mental health team responsible for her safety – and care, management and treatment – in the community, and notwithstanding the context of the Covid-19 pandemic, I found an inappropriate over-reliance upon her family members, principally her husband and son, to keep Jo safe in the community. This involved the family monitoring Jo 24 hours a day, seven days a week over an extended period and physically preventing her from leaving her home address unaccompanied.”
She added: “In the circumstances I concluded that an inappropriate over-reliance upon family members to keep such a vulnerable and high-risk person safe in the community, over an extended period of time, probably contributed to Jo taking her own life on June 12, 2021.”
A spokesperson for Essex Partnership University NHS Foundation Trust (EPUT) said: “Our thoughts and sympathies remain with Johanne’s family, friends and loved ones.
“Providing high quality, safe and compassionate care is our absolute priority, and we are focussed on making sure we learn lessons from this very sad incident.
“We are committed to continuously improve the services we provide and have already implemented several measures. These ensure risk assessments and care plans are regularly reviewed, improved discharge processes take into account individual needs, and that there is improved collaboration across different teams and services, so that patients receive the most appropriate care to meet their changing needs.
“We continue to look closely at the Coroner’s recommendations to further improve care and support for vulnerable patients.”