Family claim woman who took own life received ‘sporadic’ support from mental health services

Linda Kent was diagnosed with psychotic depression in July 2017 after she developed delusions her household appliances were poisoning her.

She died at home a year later, just five days before an appointment with a psychotherapist her family thought would be a "turning point".

Sally Spanswick, Linda's sister, said there had been a "failure to manage" Linda's treatment and "failure of support staff to provide support reliably and consistently".

She said NSFT staff saw her "six hours per month".

She said Linda was "intelligent, kind and compassionate", but was "extremely scared" of being sectioned.

Her brother had been institutionalised 13 years earlier with schizophrenia.

Linda and her husband Paul, a hairdresser, lived at Hillside Avenue in Thorpe St Andrew.

By Easter 2017 she began exhibiting delusions that their household appliances were poisoning the family, and that they were being "targeted" by malicious outsiders.

Mrs Spanswick said the family were begging for help but had sporadic support from community mental health nurses, and delays in seeing a psychotherapist.

"It had become clear while Paul was caring for Linda NSFT were leaving him to deal with her debilitating illness by dipping in and out of her care," she said.

"Paul was extremely desperate and felt abandoned by the NHS. The care given to Linda was disgraceful."

She said community nurses were unreliable and would regularly cancel appointments.

Mr Kent often had to "covertly" administer medication, and eventually Linda believed the drugs were causing her permanent brain damage.

She repeatedly told her family of thoughts of suicide, but consistently denied it to medical professionals.

Dr Andrew Few, GP at Thorpe Health Centre, made two urgent referrals to the crisis team - on May 9 and May 16, 2017.

"My thoughts were this was an evolving psychosis," he said. "She would be quite dismissive of her symptoms. She did not believe she had a mental illness.

"I was worried about her. Because she was reluctant to accept help this led to increased anxiety and fatigue for her husband.

"While her family reported her expressing suicidal thoughts she denied this on numerous occasions. In my experience people who say they are suicidal are more likely to want help. Those who try to conceal it are more likely to go through with the act.

"In retrospect you can see the warning signs but at the time it is difficult to see. The risks were there."

In August 2017 the family approached a private consultant - Dr William Crook.

Dr Crook asked Mr Kent to keep trying to make his wife take medication.

"If this failed, which I felt likely, use of the Mental Health Act would need to be considered as an option," he said.

But Dr Joan Bufton, consultant psychiatrist at the Julian Hospital, said she "did not feel the Mental Health Act was justified".

"If I had been imminently concerned about her mental state we would have looked at admission. That is our only other real option."

But because Linda was taking medication Dr Bufton felt that wasn't "the least restrictive" treatment option.

"I did not feel the Mental Health Act was justified."

Area coroner Yvonne Blake asked Dr Bufton: "Her husband works, her sister lives in the Midlands and her children live in London. Apart from the crisis team how do you manage someone like this who is at risk of committing suicide in the community?"

Dr Bufton said: "We monitor with community mental health nurse visits. We do rely on information from family members about the changing mental state."

Dr Bufton arranged appointments every six weeks and organised help from the Julian admission prevention team.

By March 2018 there was "no evidence of suicidal or delusional ideation", she said, but treatment was still needed for the "residual depression", which had not responded to treatment.

Lithium and psychotherapy was discussed, and Linda was put on a waiting list for an appointment.

But by April an amended treatment plan had seen no improvement.

"Linda was of the view her brain had been damaged by the medication," Dr Bufton said. "I would say that was the beginnings of resurgence of delusional beliefs."

On June 4 a further change to medication was delayed as the GP failed to act on the prescription.

The inquest also heard that a care plan for Linda had not been filled in.

Tina Lake, community mental health nurse, said that while the planning of Linda's treatment was verbally reviewed, she did not record it.

She said: "I can only apologise."

The NSFT said action had since been taken to improve the quality of its care plans.

A Serious Incident Requiring Investigation (SIRI) report was carried out by the trust, but the panel "did not feel" the death was a result of the care provision, the inquest heard.

Mrs Spanswick said they were "counting down the days" until an appointment with a psychotherapist on August 1.

"We thought this would be a turning point," she said.

Linda was found dead at home on July 27, five days before the appointment.

"This will never bring Linda back and she was suffering every waking moment," said Mrs Spanswick. "Her family and friends have been left with a void that can never be filled."

In her conclusion, Ms Blake said while it was clear Linda killed herself, it had not been demonstrated that she fully understood the consequences of what she was doing. She therefore ruled out suicide.

Instead, she gave a "short form" conclusion, which said: "Mrs Kent took her own life, however she had been diagnosed with severe and drug resistant depression and had episodes of psychosis, so there was no clear evidence as to her intent."