Mental health professionals did not believe that a mother of a son posed a “significant risk” to herself in the days and weeks before her death, according to research. Kate Hedges, 35, passed away at Gatley train station in November 2020, she was released from hospital in October and referred to the home treatment team.
Kate had been described as a ‘beautiful and brilliant person’ at an inquest into his death on 27 November 2020 at South Manchester Coroner’s Court. She had long suffered from mental health problems after significant trauma when she was younger, including bullying and rape when she was 19 years old. She also took care of her young son who has autism.
Yesterday, her family raised further concerns that they were not involved in Kate’s care and were not regularly consulted by either the hospital ward or the team at home to which she was discharged. On the second day of the Stockport inquest he heard how doctors in Bronte’s ward at Wythenshawe Hospital, where Kate was being treated after being isolated under the Mental Health Act, felt her condition had improved enough for the discharged to the home-based treatment team. This is despite previous ‘manic behavior’ in this room and her Kate disappearing when she was granted unaccompanied leave.
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During her time at Wythenshawe Hospital, Kate was diagnosed with bipolar disorder, which she did not accept at first, before her mental state gradually improved. The court heard yesterday from Dr. Muhammad Imran, a consultant psychiatrist at Wythenshawe Hospital, that from her admission on September 9 to his last interaction with her on October 20, she had become calmer, but he did not think she was ready to be discharged.
Despite this, on October 27, after consultation with Mr. Jon Lysons, a mental health professional on the hospital’s home treatment team, and Dr. Muhammad Iqbal, a registrar on the ward, he determined that Kate’s condition had improved enough that home-based treatment was appropriate for her. Mr Lysons said that Kate was finding the atmosphere in the room “distressing” but that she was very calm when he spoke to her.
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Mr. Lyons said he “wasn’t worried that she wasn’t ready” for home treatment and that it would be the best place for her. Dr. Iqbal led Kate’s discussion about discharge with the home treatment team, agreeing that her condition had “improved” in the weeks leading up to October 27.
“Kate was very involved and engaged in the conversation,” he told the court. “She spoke up and said she felt much better.” Dr. Iqbal added that she no longer displayed any psychotic symptoms that would have led to sectioning and that the legal justifications for her detention were no longer justified.
There was discussion with Kate about staying in the hospital voluntarily, but she was anxious to return home as the ward can be an ‘intense’ and ‘harmful’ environment. Dr. Iqbal said that Kate was responding well to her medication and that she wanted to return home to her young child.
“We concluded that discharge to home treatment was the most appropriate step at the time with Kate involved in the decision and agreeing with her,” added Dr. Iqbal. Kate returned to her home in Burnage and would soon move to Ashurst Road in Gatley.
Andrew Barron, a mental health professional with Greater Manchester Mental Health’s home treatment team, began meeting with Kate at her home every other day on October 30. He said her mental state seemed “settled.”
“I was motivated to do things and hopeful for the future,” she also said she had a good support network of friends and family. She added that she would not approach the family as part of the course as an adult without immediate protection concerns.
Kate continued to improve during her meetings, Barron said, and despite moving house she was managing just fine. Matthew Baron, representing Kate’s family, expressed concern that Kate’s family was not involved in discussions with the home-based team about her treatment. Kate had told Mr Barron that she had a ‘strong support network’ and because of this, the home treatment team ‘would not normally engage’ with the family unless there were immediate protection concerns.
After their last meeting on November 6, Jacqueline Cox, another mental health professional, became Kate’s designated worker and met Kate for the first time on November 14. she improved, having been in ‘amber’ when she was first discharged, meaning a practitioner visited her less often.
Mrs Cox described Kate as very “nice and warm” when they met. Kate had been very positive about the move from Burnage to Gatley and her mental state was good.
Area Coroner Christopher Morris told Ms Cox about evidence Kate’s sister Maya Hedges told the court yesterday (April 19) about how Kate became “withdrawn” and “no longer knew who he was” after this move. Mrs. Cox recalled Kate telling her that she was “bored” and that she wanted to get back to work. She, too, was frustrated with not being able to drive, and Mrs. Cox helped Kate come up with plans to validate these frustrations and work through them.
samaritans operates a 24-hour service available every day of the year. Call toll-free 116 123 or send an email to [email protected].
CALM has a helpline (0800 58 58 58) for men who are depressed or have hit a wall for whatever reason, who need to talk or find information and support. They are open from 5 pm to midnight, 365 days a year.
SANE line. If you have a mental health problem or support someone else, you can call SANEline on 0300 304 7000 (16:30-22:30 daily).
drink, a free and confidential helpline for people concerned about their drinking or someone else’s. Call 0300 123 1110 (weekdays 9am-8pm, weekends 11am-4pm)
Alcoholics Anonymouswhose helpline is open 24/7 on 0800 9177 650. If you prefer, you can also email them at [email protected] or chat live via their website at www.aamail.org. .alcoholics-anonymous.org.uk.
Al‑Anon offers support and understanding to families and friends of dependent drinkers. You can call their confidential helpline on 0800 0086 811 (open 10am-10pm).
“I didn’t feel like there was an escalation of risk and I wanted to help her achieve her goals,” Ms Cox said. Kate said that she had started to feel a bit depressed, but that she was still planning for the future with her child and she did not talk about hurting herself, which put Mrs. Cox at ease.
At the next meeting, Kate admitted that her medication had made her feel like a ‘zombie’ at times, but Mrs Cox still felt there were no risks to her safety or well-being at that stage. Mrs. Cox’s last meeting with Kate occurred on November 23.
“He reported improvement by taking fewer medications and had spent time with his family and a strong support network,” he said. “At the time I didn’t have any express concerns about Kate’s safety or well-being, but I was still trying to support Kate as best I could with her trying to come to terms with her illness. There were no significant risks on that last date.”
Kate was set to be slowly released to the community mental health team from then on, and a worker had been assigned to her. However, Kate died four days later.
Coroner Morris is ready to raise concerns about ‘irregular’ communication between the Bronte Ward in Wythenshawe and different mental health services within Greater Manchester Mental Health that have different note taking systems. Yesterday, Mrs Hedge’s mother, Nuala Finegan, paid tribute to her daughter saying: “Even when she wasn’t well, she was very Kate. She had an infectious laugh and her death was devastating to us.” .
The investigation continues.
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