A HEARTBROKEN mum whose daughter killed herself six weeks after she was refused psychiatric treatment in the community says she was let down by the system.
Mum-of-three Kelly Shaw, 30, was battling against debt and depression, an inquest in Carlisle heard.
She was discharged from treatment with a community mental health team in Carlisle three months before her death, but had asked her GP to restart the treatment because she wanted support.
Medical professionals refused it after deciding she was sufficiently recovered and had alternatives available.
After recording a suicide
verdict, North Cumbria’s most senior coroner David Roberts ruled there was no evidence Kelly was at serious risk when her request for treatment was declined.
But Kelly’s mum Dot Shaw, 52, said her daughter was failed.
She believes her daughter would still be alive today if she had been given more support by health professionals.
The Carlisle inquest was told that Kelly, a former Morrisons supermarket worker, was found hanged at her Springfield Road home in Harraby on April 26 last year.
Scattered on her bed were various bills showing the money she owed, including a rent arrears bill for several hundred pounds.
Tests showed that when she ended her life Kelly had been drinking – something she was told not to do because she was taking anti-depressant medication.
Described as a devoted mum, Kelly had battled depression and undergone a hysterectomy because of medical problems.
Officials from the Cumbria Partnership NHS Foundation Trust, which provides community and mental health services, said Kelly had been supported in the community but was discharged on February 2 last year because she was considered well enough to cope.
But on March 5, Kelly asked her GP to refer her back to the community mental health team, saying her mood was low and needed support. But the referral was deemed “inappropriate.”
That decision was made after the doctor and two mental health professionals – her care coordinator and a clinical lead – assessed the application and decided Kelly had appropriate help elsewhere.
Ian Boit, the health trust’s learning lessons facilitator, reviewed the case and referral refusal.
He said it was difficult to challenge the decision, given that it involved three professions.
“It was an appropriate decision,” he said.
“Despite that she still had contact with a social worker, with Barnardos; she was told she could self-refer and be directed towards another counselling service, so she had other opportunities to get counselling.”
Mr Boit did, however, recommend patients refused treatment should get a letter explaining why and suggesting alternative services. He also accepted it would have been good practice to contact Kelly’s mum, who was supporting her.
In her evidence, Dot said: “When Kelly was asking for help it was because she couldn’t cope.
“If somebody had just taken the time for Kelly and said ‘we will sort out your bills’, got her back to thinking it’s not all black, all gloom, to say you’ve got depression but we can help you through this to a better place. That’s what it would have taken.
“I feel she’d still be here today if she’d been given that help.”
Delivering his conclusion, Mr Roberts said the evidence pointed at the time she was discharged to Kelly no longer needing specialist input. Nor was there evidence of her being at risk.
Her GP considered her more stable, he said.
The coroner noted she had faced stresses in 2014 – including her operation and splitting with her partner.
But he added: “She had clearly drunk alcohol that night – something she had been advised against. On her bed were various bills.
She owed a lot of money, was on benefits. “I’m satisfied she was reminded of those debts and her lot in general. I’m satisfied she acted impulsively and that she would not have done that had she been sober.
“Having been reminded of her lot, she decided deliberately to end her life.”
Commenting after the inquest, Dot said: “They continued to discharge Kelly even though she had missed her last appointment. How could they do that without speaking to her?
“I feel Kelly was let down by the system.
“She was such a lovely, caring person. She was open and honest – a loving daughter and a devoted mother. I feel that if they had communicated with her properly she would still be here today.”
A spokeswoman for Cumbria Partnership NHS Foundation Trust said: “We offer our sincere condolences to Miss Shaw’s family at this very difficult time.
“The trust has taken her death very seriously and immediately undertook an internal investigation, the outcome of which we have shared with the family and coroner.
“As part of this investigation, there were areas that should have been better and this has led to the introduction of improved processes for sharing information between services and patients when a referral is declined.
“However, the coroner was clear in his summing up of the evidence that these changes would not have prevented Miss Shaw’s death.
“We are committed to providing the best possible patient care.”
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