A National Health Service Trust “has not been covered in glory” in its dealings with the family of a vulnerable young woman who killed herself after being denied hospital admission, a coroner has found.
The three-day hearing looked at evidence withheld from the original investigation into the death of Sally Mays, who killed herself in 2014 after being turned away from a mental health unit.
Mays was reprimanded for “negligence” by the staff at Miranda House in Peelruled in a 2015 inquest, after a 14-minute evaluation led to him being denied a spot, despite being a suicide risk.
Her parents, Angela and Andy Mays, won a court battle in December to overhear details of an informal conversation outside the building between Laura Elliot, a community mental health nurse who supported Mays, and consultant psychiatrist Dr. Kwame Fofie, who only later did it come to light.
The court heard as Elliot was comforted by Fofie, who was not involved in Mays’ case at the time, after becoming upset when the unit’s crisis team did not accept Mays, who had become so distraught that she needed to be restrained.
On Wednesday, the lead coroner, Professor Paul Marks, ruled that this was “neither a clinical conversation nor an attempt to heighten his care”.
He said: “It was a conversation between colleagues in which the frustrations of the working day were aired.”
But, he said: “The trust has not covered itself in glory regarding its dealings with the family and the release of documents.”
Angela Mays told The Guardian that she now considers the case solved.
“I think we are relieved that we have finally reached the end of the legal process and the information that we have been seeking for the last seven years has finally been revealed in full,” he said.
The Mays have spent the last seven years struggling to hear the details of the conversation in the parking lot, which could have changed their understanding of what happened before their daughter died.
Angela Mays added: “I never considered myself an activist. I have only considered myself a mother who really wants the truth about the facts related to the death of her daughter.”
On July 25, 2014, the Humber NHS foundation trust took Mays in for assessment after becoming distraught.
The conversation in the parking lot came after Paddy McKee, the crisis team nurse who conducted her assessment, denied Mays a place in the unit. McKee has since been removed from the nursing record.
Elliot told the court that she was upset and angry that Mays had been rejected and also that “the crisis team had never spoken to her so unkindly.”
The nurse described a five-minute conversation in which she unburdened herself with Fofie, who was “supportive and validating.”
Both the nurse and the doctor did not feel that the conversation was relevant to the investigation, as it was informal.
Elliot said: “There was no reason, I felt at the time, to tell anyone.
“It was a conversation about me, my feelings.”
This second investigation does not change the findings of the 2015 investigation that found another missed opportunity to save Mays’ life was due to a 69-minute delay in the arrival of an ambulance after the call was not properly classified, the report said. forensic.
It concluded that Mays’s actions “undoubtedly caused her death”, but “her intentions remain unknown”.
Michael Rawlinson, representing the Humber NHS Foundation Trust, said the trust “unreservedly apologized” for the fact that the parking conversation had not come up earlier and that a second investigation had been required.
