A coroner has concluded that the death of an NHS manager who took her own life could not unequivocally be attributed to lapses in her care.
Jonathan Leach, assistant coroner for North Yorkshire and York, said today (Wednesday, March 23) that it was “not possible to say whether these (lapses in care) caused or contributed” to the death of 56-year-old Frances Wellburn, who had been plagued by psychosis and depression.
Mr Leach delivered his narrative conclusion following a two-day inquest in Northallerton in which Frances’s sister Rebecca Wellburn quizzed health workers from the Tees Esk and Wear Valley NHS Foundation Trust (TEWV) about how her beloved sibling went three months without weekly care visits before her tragic death in 2020.
Former NHS manager Frances Wellburn died at her home in Fulford in July 2020.
She had been suffering from psychosis and depression but the care she had been receiving prior to the Covid pandemic in the spring of 2020 appeared to dissipate when the country went into lockdown.
The 56-year-old former health manager, described as a “gentle, caring” woman, suffered from delusional thoughts, anxiety and depression and should have had weekly check-ups from mental health workers at the Tees Esk and Wear Valley NHS Foundation Trust (TEWV).
However, it’s understood that Frances was not visited by specialist health workers for three months after the pandemic broke out in the UK.
Alison McGrath, a mental health nurse with the NHS trust, said there had been no “recorded contact” with Frances for at least two months up to the beginning of May 2020. Four months later, she was found dead at her Victorian terrace house in York.
“There was no evidence that she was seen by anyone in March or April either,” added Ms McGrath.
Other patients had been seen on a “face-to-face” basis, but Frances was assessed as not being at a high risk of harm under the NHS’s risk-rating system. She was given an amber rating – one below red, or high-risk.
She was not referred to the trust’s RAG (Red, Amber, Green) team despite relapses in her mental state.
‘Missed opportunity’
Ms McGrath, giving evidence on the first of a two-day inquest in Northallerton, said she believed the amber rating was correct at the time.
But she added that referrals should be made “at the first point where psychosis has been suspected”, which, in Frances’s case, may well have been as far back as September 2019 if she had been displaying signs of “psychotic depression”.
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In her report following Frances’s death, Ms McGrath said there were “significant gaps” in her care.
She said there may have been a “missed opportunity” in not formulating an action plan for Fracnes which involved input from her family.
She said although Frances had been getting help from mental health nurses, she may not have had the necessary professional psychological therapy in the run-up to her death. This could have included specialist help from consultant psychiatrists and occupational therapists.
She added, however, that it was “difficult to say” whether this would have made a difference to Frances’s mental deterioration.
There had been no “risk update” or care plan for Frances between October 2019 and her death in July 2020 despite her having made a second suicide attempt.
‘Very high risk patient’
In 2019, Frances, who lived alone, was sectioned under the Mental Health Act after suffering psychotic episodes and spent three weeks at Cross Lane Hospital in Scarborough.
She was discharged into the care of a community team whose job it was to check in on her on a weekly basis, but an internal report found that during the first coronavirus lockdown in March 2020, Frances went three months without contact.
Jon Gosnold, a community psychiatric nurse with the NHS trust, said he detected “no real change” in Frances’s condition when he last visited her in December 2019 and she showed no sign of wanting to take her own life, although she still had “psychotic and delusional beliefs”.
Dr James Sampford, a psychological specialist with the Tees Valley trust, said Frances was a “very high-risk patient” in the long term but this didn’t necessarily mean there was a risk of self-harm.
When asked if he thought it was appropriate for Frances to be released back into the community following her hospital admission, he said it was.
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Police found Frances’s body on August 2, 2020, after her sister Rebecca Wellburn told police and mental health workers that she had not been in touch for days.
Frances’s neighbour, who was named at the hearing, said her friend “always had a great love of her family” and was very close to her siblings.
She said that the last time she spoke to her, about two weeks before her death, Frances “seemed in good spirits”.
She described Frances as “vibrant, very gentle and caring” and always “seemed happy”, although a month earlier she looked “tired and unwell, physically withdrawn”.
She said that Frances seemed “withdrawn and quiet” after being discharged from her latest hospital admission in July and “didn’t seem to bounce back from her normal self”.
Frances’s family claim that her death was preventable and that she was let down by the mental health trust.
‘Planning to work together’
Elizabeth Moody, director of nursing and governance at the trust, said after the inquest: “Our hearts go out to Frances’s family and friends during this incredibly difficult time. We remain deeply sorry for their loss.
“Providing the best possible care for the people we support is the most important thing we do, and we have worked hard to make improvements following our own review into Frances’s tragic death in 2020.
“We shared our findings with Frances’s family and we are planning to work together to support further learning and improvement in our community mental health care.”