A YORK woman has taken her own life following lapses in her mental health care during the first lockdown, an investigation has heard.
Frances Wellburn was not visited by the community mental health team after the lockdown began in March 2020 and suffered a relapse in May.
Police found the 56-year-old woman, suffering from psychotic depression, dead at her home on Main Street, Fulford, in August 2020, after her family raised the alarm.
Coroner Jonathan Leach, who described Frances as an “independent, intelligent and resourceful” woman, said today that a review after her death found flaws in her care, but it was not possible to say whether they contributed to or caused her death.
Frances’s sister, Rebecca, later told The Press that for 55 years, Frances had lived a “full and active” life, but in her last 10 months she had suffered from a severe bout of psychotic depression.
“There is every reason to believe that with proper care he would have recovered from this,” he said.
“In fact, Frances had started her recovery in early 2020 and instead of taking advantage of this, she had no contact with her mental health team at all.
“We do not believe that his relapse in May was inevitable. It seems clear that he was involved in the medication interruption during the three-month period in which he had no contact with the services.
“I am pleased that the coroner has considered these events within the scope of the investigation. Significant gaps in care are an essential part of understanding the series of events that led to his death.”
He said he hoped the Tees, Esk and Wear Valleys NHS Foundation Trust, which provides mental health care in York, would acknowledge that it could have done more to support Frances’s recovery and prevent her tragic suicide.
Elizabeth Moody, the Trust’s Director of Nursing and Governance, said: “Our hearts go out to Frances’s family and friends during this incredibly difficult time. We deeply regret the loss of her.
“Providing the best possible care for the people we support is the most important thing we do, and we have worked hard to make improvements following our own review of Frances’s tragic death in 2020.
“We share our findings with Frances’s family and plan to work together to support further learning and improvement in mental health care in our community.”
He said the improvements included:
•Developing a caregiver forum to enhance the caregiver experience
• The splitting of two community mental health teams in York and Selby into four teams in September 2020, to provide better oversight of senior and operational clinical practice, increased capacity to manage caseloads and clinical oversight of staff .
• Training on the importance of the documentation standard, in particular in relation to the evaluation, management and registration of clinical risk.
• The introduction of professional practice development to support quality standards of care.
• Updating the staff’s knowledge of the operational policy related to early intervention in psychosis and the criteria and processes for accepting referrals.
Contact York Samaritans at www.samaritans.org or call toll free 116 123
