Before HM Assistant Coroner Catherine Wood North East Kent Coroner's Court 23 January 2024 – 25 January 2024 and 27 March 2024 – 28 March 2024
Tara Wakefield died on 14 September 2022, aged 51, at Margate Cemetery, following repeated and escalating self-harm and suicide attempts over several years, including an attempted overdose on 20 August 2022, which resulted in a two-week inpatient hospital admission to Queen Elizabeth the Queen Mother Hospital (QEQM) less than a month before her death.
The inquest concluded on 28 March 2024 and the coroner identified failings relating to Tara's care but considered there was insufficient evidence to say these failings were causative of Tara's death.
Background
Tara's family describe her as a caring person who was bubbly and fun to be around, and who laughed easily. She loved animals of all kinds, but especially dolphins and gorillas, and loved her family, who were her world.
Tara had a diagnosis of temporal lobe epilepsy. She also had a long history of overlapping mental ill health, including depression for which she first received treatment in around 2000. Tara's consultant neurologist considered that while the situation was complex, her symptoms may have been psycho-social in origin.
The nexus between Tara's mental ill health and her epilepsy was explored at the inquest. Her family outlined that Tara would self-report that her issues were all based around her epilepsy – including her various self-harm and suicide attempts which she attributed to “fear and dread” seizures – but her family, her GP, and neurology and epilepsy professionals working with Tara considered this was linked to her underlying mental ill health, typified by anxiety, depression, and paranoia.
In the final years of her life, Tara grew increasingly paranoid about her living conditions, and expressed fears to friends and family that people were breaking into her home, tampering with her food and drink, and drugging her. She began self-neglecting – afraid to cook, or to eat food stored in the house in case it had been tampered with. Her family's concerns about her increasingly deteriorating living conditions, her paranoia escalating, and her repeated attempts to self-harm, reached the stage where, following an attempt by Tara to take a “huge overdose” and cut her wrists in February 2021, they tried to seek additional mental health support and asked for her to be sectioned. Despite the family raising concerns, Tara was discharged from Priority House with her family advised that she “just needed fresh air”. Tara's self-harm and suicide attempts continued thereafter and escalated.
During this time, Tara sought support from various bodies to be rehoused. The inquest heard evidence that Tara was fixated on Copperfields, a residential home in Ramsgate, where she believed she would be able to access appropriate support. In November 2021, Tara's Kent County Council (KCC) social worker presented a case for her to be housed at Copperfields at a panel. However, the application was incomplete and included inaccurate information regarding Tara's needs including detailing that she required injections of medication during seizures. Copperfields refused to rehouse Tara there due to concerns about keeping Tara safe, and in particular regarding the supposed administration of injections which staff on site would not be qualified to do. KCC were invited to re-submit the case with further information. This was never done.
In the course of the inquest, it emerged that KCC had failed to disclose to the coroner or other Interested Persons details of a complaint lodged by Tara in respect of her social worker, these documents were provided by another witness. The complaint included allegations that Tara's social worker had on various occasions:
- Dismissed Tara's expressions of distress, telling her “just stop crying”and to “pray then”
- Responded to Tara's fears about losing her life by telling her that “my God will not let you die”
- Told Tara that a woman in her position “should be grateful just to move anywhere” and her case was not as important as others she was supporting
The social worker did not give evidence at the inquest. Her manager, however, acknowledged that this conduct was not appropriate. The family still have not received any explanation as to why these records were not disclosed by KCC.
On 20 August 2022, Tara was found by emergency services by the edge of a cliff, unresponsive, having taken an overdose. She was admitted to QEQM hospital. Her paracetamol levels were toxic, and treatment was commenced to prevent liver damage. Tara reported to hospital staff that she had intended to end her life. She attempted to leave the ward, and was threatened with detention under s.5(2) of the Mental Health Act which is a power that allows doctors to detain someone in hospital for up to 72 hours to receive a mental health assessment. She subsequently agreed to stay as a voluntary patient.
Tara was assessed repeatedly by the Liaison Psychiatry Service run by Kent and Medway NHS Social Care Partnership Trust (KMPT) while on the ward and was initially assessed as at high risk to self.
Her family provided a folder of evidence they had been collecting to the ward – which included previous suicide notes from Tara, photographs of her living conditions, and screenshots of messages showing her paranoid ideation. They asked that this material be provided to the psychiatric team assessing Tara.
Dr Chapman, the junior doctor on Tara's ward confirmed in oral evidence that he showed this folder to consultant psychiatrist Dr Mondeh before his assessment of Tara. Dr Mondeh, however, denied that this happened, though his evidence in this regard was ultimately not accepted by the Coroner at the inquest.
In the course of Dr Mondeh's evidence at the inquest, he provided his own version of his notes of his assessment of Tara which did not match those previously provided by KMPT, or stored on the KMPT system.
Dr Mondeh said that Tara's problems were neurological. When asked about whether he ought to have obtained input from a neurologist before making that assessment, Dr Mondeh stated he did not need neurology input and referred the court to a document he had brought with him about temporal lobe epilepsy. When asked about the provenance of the document, he stated that it was one he had “got from the internet”.
Tara's final assessment by KMPT was carried out by a mental health nurse, Patricia Longman, who downgraded her risk level to low, and discharged Tara to her GP with no community follow up. This was despite concerns being expressed by the ward staff about this proposed plan of action. Tara was discharged from hospital for the final time on 1 September 2022. She died less than two weeks later having hung herself in Margate Cemetery.
A Root Cause Analysis (RCA) investigation conducted by KMPT following Tara's death concluded that Tara should not have been discharged without any follow up, and she should have been discussed within a multi-disciplinary team (MDT) environment. Despite this, Ms Longman at court maintained that her action to downgrade Tara's risk of self-harm to low and discharge her from hospital with no support was appropriate, and reported having no knowledge of the findings of the RCA investigation.
The Inquest
The coroner ultimately concluded that while there were failures in Tara's care including a failure to appropriately consider and take into account documentation from Tara's family, a failure to refer Tara to the community or home treatment team, and a failure by various bodies to coordinate between themselves and take responsibility for Tara's care. However, the coroner did not consider she had sufficient evidence to conclude that these were causative of Tara's death.
Trudie Belsey, Tara Wakefield's daughter, said:
“Watching mum's declining mental health in the last few years of her life was extremely painful for our family. One of the hardest parts was that we as a family could see she was struggling, and needed professional help, but we didn't know how to get her the help she needed. Too often, it felt that we were not taken seriously when we raised our concerns with professionals.
“Sitting through the evidence in mum's inquest was hugely difficult and distressing for our family, but it seemed to me throughout that, with few exceptions, there had been a culture of professionals and organisations all hoping one another would do something rather than taking proactive steps to protect an extremely vulnerable woman. All we can hope is that lessons have been learnt from what happened to mum, so no other family has to deal with their loved one falling through the cracks of a failing mental health system again but I am not confident that this is the case.
“I was particularly concerned to see, only weeks after mum's inquest had concluded, the case of Gabriel Farmer which has so many parallels with mum's case. Like mum, he was admitted to the QEQM after a suicide attempt in the context of a history of mental health issues and previous suicide attempts. Like mum he was assessed as low risk by the same nurse, Patricia Longman, and was discharged from hospital. And like mum, he sadly died shortly afterwards.”
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