'I will be dead in an hour'.
Those were the words blogger Beth Matthews uttered to a staff member on a secure mental health ward in Stockport just moments after swallowing the poisonous substance that killed her.
Beth was just 26, a child support worker and a hugely talented sailor. She also had a blog. In 2019 she had tried to end her own life by jumping off a bridge. She survived, started her blog and acquired a massive online following.
Her first suicide attempt led to injuries so severe they left her in 'significant long-term pain and disability’.
However, with her regular open and honest online updates about her journey, she touched the lives of so many people struggling themselves, and she always tried to help those who reached out to her.
Following her death, Beth's sister Lucy said she has been told her sister's writing saved people's lives.
READ MORE: Hospital neglect contributed to death of blogger Beth Matthews who died after ingesting toxic substance, inquest concludes
But, despite the impact she had on others, an inquest into Beth's death found she was neglected by the very people who were supposed to care for her.
As her mental health again deteriorated, she was consumed by thoughts of wanting to end her life. And on March 21, 2022, her life did end. In the most tragic of circumstances.
Beth had ordered the substance, which the Manchester Evening News is not naming, on the internet from a supplier in Russia and had it delivered to The Priory’s Cheadle Royal Hospital where she was a patient and was being detained under the Mental Health Act.
She was then able to open it and consume an unknown, but what transpired to be a fatal amount, in front of staff - despite them trying to restrain her in a bid to stop her. For the last fortnight, an inquest at South Manchester Coroner’s Court in Stockport has been looking into exactly how this was able to happen.
Beth was the third young woman in two months to die at the Cheadle hospital unit. Lauren Bridges and Deseree Fitzpatrick died in the same facility just weeks apart.
A jury have now concluded her death was the result of suicide, contributed to by hospital neglect.
Returning their findings today (Thursday, January, 19) they said Beth was a 'complex patient' who was considered at a 'high risk of suicide' due to her 'frequent suicide attempts including ordering packages to assist this.'
They said her actions 'prior, during, and post the opening of the package and ingestion were executed with full intent and awareness of the consequences.'
'Caring, 'intelligent' and articulate'
Elizabeth Frances Matthews, known as Beth, was from the village of Menheniot near Liskeard, in Cornwall. She was described as a 'bright and vivacious girl' who would 'light up the lives of everyone she met'.
In a moving pen portrait read at the inquest, her mum Jane Matthews described her daughter, who she said was 'proud to call herself a Cornish girl', as 'caring, 'intelligent' and articulate' with a 'quick sense of humour.’
She said she was a talented sailor who won 'lots of trophies' and competed nationally including in the renowned Fastnet race aged just 15. She was then invited to become a member of the Royal Yacht club as a result of her ‘outstanding’ performance.
She also played both the guitar and the piano and was an animal lover, with her pets including a dog, pony, hamster, chickens, guinea pigs and her ‘beloved’ cat Sparkles, who she once spent an entire summer camping on the front lawn in order to be closer to.
Ms Matthews said her daughter was 'unable to reach her full potential due to the mental illness which overshadowed her later years’, but that she was ‘able to touch the lives of so many people.’
Beth first sought help with her own mental health in 2011 when she was just 16. At the time she was thought to have a depressive disorder and was referred to her local child and adolescent mental health service. However, the inquest heard her parents were not aware of this and when her school informed them she immediately stopped attending appointments.
Her ex-partner Matt Parkinson, who she met whilst working at a water sports centre in 2014, before they bought a house together in around 2017, said she was initially ‘very protective’ around her mental health and ‘shared very little’ about it with him or her family. However, he said as time went on, her problems became ‘more noticeable.’
She was formally diagnosed with Emotionally Unstable Personality Disorder (EUPD) following a hospital admission in October 2018. The doctor who gave that diagnosis, her consultant in the community and during the periods she was in hospital in Cornwall, Dr Alind Srivastava, said the condition is characterised by intensely fluctuating emotions, emotional outbursts, a ‘'sense of emptiness, rejection and abandonment’ as well as 'difficulties with relationships’. ‘
There’s also impulsivity’ he said ‘for example self harm or other actions that can then be regretted sometimes.’ Up until her death this was a diagnosis Beth questioned and disagreed with, the inquest was told, her being of the opinion she only met some of the criteria for it. Dr Srivastava said he consulted a colleague who agreed with his diagnosis.
In 2019, Beth’s life was to change forever.
On Saturday, April, 6 she was picked up by police on a bridge in Cornwall having ‘threatened to jump’, the inquest heard, and she was taken to hospital where she was assessed the following day. The decision was taken not to detain her under the Mental Health Act and she was released.
The following day, Monday, April 8, she went back to the very same bridge, and jumped. Beth later described how following her 50ft fall, a police officer ran to her and held her hand before paramedics arrived and she was airlifted to hospital. She suffered a catalogue of serious injuries including a collapsed lung, a lacerated spleen, lacerated liver and lacerated stomach, broken legs, broken ankles, a broken femur, an unstable spine fracture and pelvis fractures causing permanent nerve damage.
She spent two weeks in a coma on an intensive care unit at Derriford Hospital in Devon, and spent several months at the hospital having further treatment, before being sectioned and transferred to the Fletcher Ward, a psychiatric ward at Bodmin hospital in her home county.
After being discharged in September 2019, Dr Srivastava said she was having dialectical behaviour therapy ‘very regularly’ and that was accompanied by a ‘period of stability’ in her mental health.
“I don’t think she was ever fully thrown from thoughts of wanting to be dead, but there were periods where it was very much in the background and was not an immediate concern” he told the inquest.
“Don’t suffer alone and hope it will go away."
It was during her recovery, following the life-changing bridge fall, that she decided to start documenting her experience, in her blog called ‘Life Beyond the Ledge.’
In it, she said: “I have always hidden my mental health struggles, even to the point where I tried to take my life to stop people knowing. But last September (2019) I shared my story on Facebook about what all I had been through since the day I jumped, 5 months prior.
“It was not an easy decision to make, far from it, but there were only so many excuses I could come up with when asked about my injuries, time I’d spent in hospital, absences, and many other things. I can hand on heart say that from the moment I clicked publish, my life has changed dramatically, and every single change has been for the better.”
She added: “I was really nervous and unsure whether to post this or not but I’ve realised it’s happened, it is a part of me now and I can’t change that. If I can’t talk about it, why should I expect other people to? Many people ‘don’t know what to say’ or ‘don’t want to make it worse’ but its ok, it doesn’t and it won’t. I am still me.
“This is just the start for me and I hope one day I can use all that I’ve gone through to try and make a real difference. I’ve met some truly amazing, caring and supportive people throughout these past 5 months. No matter how tired, exhausted or run down they may have been, they all went above and beyond to help me and I can’t thank them enough.
“If you or anyone you know is struggling or if you are worried about them please, please take some time just to talk. Find someone you trust. Friends, family, teachers, doctors, police, whoever it may be. Silence can kill. You never know who might be suffering or if it might happen to you.
“Don’t suffer alone and hope it will go away. Use this moment now to reach out and get help or check in on someone you care about.”
She provided graphic descriptions of her injuries and the ‘indescribable pain’ they caused her. She documented in detail her mental heath journey, her treatment, and her interaction with mental health services, saying she wanted to show the ‘raw reality of what mental illness can do.’
“Dressing it up to make it something that it isn’t just further stigmatises suicide and makes people hide from the truth” she wrote.
She published links to her blog and also posted updates on social media, in particular Twitter, describing herself in her biography on the site as a ‘major trauma patient, mental health patient, spinal cord Injury, ICU Survivor, suicide survivor.’ By the time of her death she had amassed 26,300 followers.
Her mum Jane said in her statement read at the inquest that her ‘massive’ following was illustrative of how ‘people were attracted to her personality.’ "She touched the lives of so many people," Ms Matthews added. "And as a result she was able to help those who reached out to her."
One of those people was Sarah Page, a friend of Beth’s who met her through Twitter and also gave evidence at the inquest..“ She used the account to reach out to those suffering” she said. “It was clear that she was trying to do the best with her experiences and help others. It was through this account that we met. She would talk to me about her struggles when she didn’t want to talk to anybody else.”
As well as blogging about her experience, Beth also raised money for the Devon Air Ambulance, who transported her to hospital, and helped in the training of police negotiators, the inquest heard.
In May 2021 she met the ‘brave’ police officer who she said ‘saved my life.’
A tweet containing pictures of her with the officer was liked over 8,000 times she said: “This moment meant the world and reminded me just how grateful I am to be alive.”
"I’m going to grab this opportunity with both hands"
Sadly for Beth and all who loved and admired her, in 2021 her mental health again deteriorated and her suicidal thoughts returned.
Her ex-partner Mr Parkinson said this coincided with the two year anniversary of her fall from the bridge. He said she believed she 'wasn't going to make any more recovery’ from her injuries and ‘sort of gave up all hope really.’
It was on May 28, 2021, that she was sectioned under the Mental Health Act for the final time, after being taken for an assessment by police following information from a friend. She was initially detained under Section 2, however in June this was ‘upgraded’ to a detention under Section 3 of the act, which lasts for an initial six month period, a decision Dr Srivastava said she was 'very angry' at. However he said he believed she was ‘determined’ to end her life and she needed to be kept in hospital to be kept safe.
As DBT therapy couldn’t be given on the acute unit where Beth was being held, the decision was made to transfer her to a specialist facility, of which the Fern Unit, a 10-bed facility dedicated to females with personality disorder, at the Cheadle Priory was one of only a handful in the country. Funding for Beth, an NHS patient, was secured for her treatment at the private hospital. She spoke about the move on Twitter saying: “Real mixed emotions but after over 5 months here on the acute ward with no real help, psychological input or therapy, just merely existing, I’m going to grab this opportunity with both hands.”
Despite initially appearing to engage with her treatment on the ward there was a ‘deterioration and a disengagement’ in the months and weeks leading up to her death the inquest heard. On March 3, a friend Ms Page said Beth told her over text someone in the ward had killed themselves and said ‘it will be me next, I promise.’ In her last Tweet, posted on March 10, Beth said she was “struggling so, so much” and apologised for ‘being so negative.’
The inquest heard that the upcoming three-year anniversary of her previous suicide attempt, the possibility of funding for her stay at The Priory being withdrawn and her having to return to hospital in Cornwall, and a looming tribunal to challenge her section, were all likely factors to have had a 'negative' impact on her mental health in the lead-up to her death.
Her relationship with her long-term partner Mr Parkinson had also broken down. He told the inquest that she broke off their relationship before 'changing her mind' and 'asking him to reconsider'. He said she in March had said some ‘unpleasant things’ but that it was his intention 'to get our relationship back together when she got out of The Priory', adding 'I thought that she would want to do that too despite what she had said before.'
The inquest heard on March 15 she attempted to call Mr Parkinson 41 times in less than an hour and that she followed it up with a WhatsApp message in which she said she was 'completely heartbroken.' He said lots of his phone conversations with Beth around that time were 'negative' where she would be telling him about 'incidents' which he said included 'attempting to abscond, not eating or drinking, that sort of thing.'
"I felt she would be safe, because of the plans that were in place"
Following an interrogation of her phone by the police, it has now emerged that she had also carried out a number of internet searches around ways to end her life, including frequently accessing a ‘forum’ with thousands of threads discussing suicide and suicide methods.
Earlier in the hearing, Coroner Andrew Bridgman said he thought it seemed ‘strange’ that patients in mental health facilities such as The Priory had ‘unfettered access to the internet’ including ‘foul’ sites that ‘assist and encourage’ suicide.
However, David Watts, director of risk and safety for The Priory, said it was ‘impossible’ to monitor patient’s web browsing on mobile phones, and that mental health units are left ‘playing catch-up’ in efforts to protect patients from certain online content.
He explained that while the unit’s WiFi has a firewall, patients could access certain websites through their 4G and 5G connections, which staff have ‘no control over.’
‘Frequent’ searches for the substance Beth ordered began from February onwards, Police Coroner’s Officer Claire Smith told the inquest.
These included searches on how it can be purchased, deaths but also ‘non fatal intoxications’ from it and scientific papers on how it is dealt with by healthcare professionals Ms Smith said. The package which she ordered was received at The Priory at 10:42 on the day she died.
Police enquiries found it had come from the Russian Federation, leaving by air mail on March 10, before being received at Heathrow Airport on March 19 and moved to the Cheadle delivery office. “Beth accessed the tracking record on March 19” Ms Smith said.
The court heard that following their enquiry Greater Manchester Police (GMP) were ‘satisfied’ that Beth ordered the substance herself, and that there was no criminality involved in her death, including by The Priory.
On March 3, Beth told a mental health nurse during a conversation that 'there are things you can purchase that can do the job.’ When questioned on this she responded: "It's already done now. I've said too much." Beth’s consultant said this 'should have’ been reported to him, as had he known about it he would have triggered an immediate review of her care plan.
The staff member involved, Leanne Williamson, told the hearing she ‘didn't feel overly shocked’ by the comment as ‘a lot of our conversations were about death or dying.’ “I felt she would be safe, because of the plans that were in place” she said.
At the time of her death, it was documented in Beth’s care plan, and also in ward handover notes that she shouldn’t be allowed to open her own parcels the inquest was told. Her Twitter biography contained a link to a ‘wish list’ of items on Amazon and the inquest heard she often received packages from her followers.
However, whilst at The Priory Beth had ingested two items and was known for ‘secreting’ banned items from the parcels the hearing was told.
The handover document completed by staff who had worked the night before for the day staff on Tuesday, March 21, the day she died, said: "Staff must open parcels for EM. Risk of secreting items from parcels" jurors were told, which was a ‘repeating’ entry.
The jury heard that each day at the unit a Healthcare Assistant was designated staff member for ‘Security, Post and Alarms’ who was responsible for distributing mail to patients. Staff said there were three different protocols for opening mail on the unit, depending on the risk; with them having to be opened in front of the ‘security officer, them having to be opened with two members of staff ‘very close at arms length’ to the patient, or for parcels to be opened for them. Mr Heathcote said it was a "very unusual thing to do, to be opening parcels for somebody” and that the standard practice was the two staff at arms length.
Despite the decision having been made to not allow her to open her post, an investigation by The Priory found there had been an ‘inconsistent approach’ to the delivery of Beth’s care plan, with some staff members allowing her to open her own post, but some opening it for her.
On March 21 when shortly before 1pm she approached the nurses' office and asked if she had any post, Beth, who at that stage was on one-to-one observations, was accompanied to the unit’s ‘Quiet Lounge’ by that day 'designated security officer Olivia Woodruff and her colleague Megan Tiplady.
“I had never opened parcels with Beth so I didn't know the correct procedure for her," Ms Woodruff said. She said she asked Mr Heathcote and was told something along the lines of that ‘it was okay for Beth to open parcels as long as we were at arm's length, which we were.'
Before she opened the mail, Beth’s leg was ‘bouncing’ Ms Woodruff said in what she believed to be ‘an anxious thing.’ She opened three packages containing a hoodie and e-cigarette coils, both of which were taken from her, 'without question.’ The fourth package she opened contained the poisonous substance. From the packaging, said to have 'foreign writing' on it, Beth is said to have pulled 'a small plastic, screw top container the type tablets would normally be held in'.
However, Ms Woodruff and Ms Tiplady said they could not see the label, which is said to have contained the name of the substance, as it was facing into her hand. They said they asked what was in it and she said ‘protein powder’ as she ‘wanted to try it.’
However, she failed to respond to further questions about it and unscrewed the lid, pierced the film, and 'started pouring the contents into a cup.' It was at this point they stood up and began restraining her to prevent her from drinking from it.
After they grabbed hold of her, Ms Tiplady said that Beth was 'adamant she wasn't letting go.' "We tackled her with the cup all the way to the door of the quiet lounge," she told jurors.. "I didn't want to let go and neither did Olivia. But we needed to press the alarm as we were struggling to stop her from drinking what was in the cup and we needed more assistance.
"Beth was too strong. There was still the tub in the room. Olivia said to me 'are you going to press your alarm?' We were scared to let go." She said as she pressed her alarm Beth 'managed to come out of the restraint, grabbed the tub and put it in her mouth.'
Ms Tiplady said Beth then 'rushed out of the room' and that she tried to grab her but at this point, there were no other staff around to restrain her so she let go and followed her. She said when she got to Beth's room she was 'using water from the tap to swallow what was in her mouth.'
As she left her room, Ms Tiplady said: "I tried to speak to her but she didn't want to respond. She looked angry. She walked back into her room and firmly stated: 'I will be dead in an hour.'” Beth's friend also received a text message containing the same comment.
Ms Woodruff said she took the bottle to the nurses' office. None of the staff on duty had heard of the substance and resorted to googling details about it she said.
Alerts had been issued by the Priory about the poisonous substance in 2018 and again in 2020, the inquest heard, and Mr Bridgman said it was 'surprising that none of the staff knew anything about it.'
As soon as the nature of it became clear an ambulance was called. However, she quickly became seriously unwell and said she was struggling to breathe. She suffered a cardiac arrest and after the arrival of paramedics, she was taken to Wythenshawe Hospital but resuscitation attempts, which included the administering of another substance to try and counteract what she had taken, were not successful and her death was declared at 3:55pm.
A pathologist gave her cause of death as a blood condition caused by ‘poisoning’ of the substance. Staff who were on duty on the ward that day were all offered counselling following the incident the hearing was told.
Following her death tributes flooded in for Beth, including from many of the people she had helped through her blogging and use of social media.
A mental health nursing student called Helen said: "So incredibly sad to hear of the passing of Beth Matthews. She was an inspiration to many and I am sure she saved a lot of lives with her brutally honest experience of mental illness. I, and many other hope she is finally at peace.”
Whilst the charity Mental Health UK said Beth's ‘work and advocacy in mental health has touched and helped many people, and her commitment will be forever remembered.’
In a statement read to the inquest jury before they began deliberating, The Priory Group said they 'accept that the care plan in place was not followed on the date.'
"They also accept it should have been followed" the statement continued. "The Priory Group accepts on the balance of probabilities that if the measure related to post on Beth’s care plan was followed she would not have ingested the substance and would not have died as she did."
A spokesperson for the Priory said the hospital accepted the findings of today's inquest.
“We want to extend our deepest condolences to Beth’s family and friends for their loss. Beth’s attempts to overcome her mental health challenges had been an inspiration for many," the said. "Although unexpected deaths are extremely rare, we recognise that every loss of life in our care is a tragedy.
"We fully accept the jury’s findings and acknowledge that far greater attention should have been given to Beth’s care plan. At the time of Beth’s unexpected death, we took immediate steps to address the issues around how we document risk and communicate patients’ care plans, alongside our processes for receiving and opening post. Patient safety is our utmost priority and we will now review the Coroner’s comments in detail and make all necessary, additional changes to our policies and procedures.”
Beth’s family now say they hope lessons can be learned and that others won’t have to suffer as they have.
In a statement, they said: “We would like to thank the coroner, jury and our legal representatives Leigh Day for their diligence in ensuring there was a thorough investigation into Beth’s death.
“The passing of Beth that day was wholly avoidable and her death was completely unnecessary. We have been tragically let down by the Priory, who we believed were providing a safe place for Beth and the care that she needed.
“Mental health care providers must listen to and act on the findings of this inquest. It is incumbent on them to keep their patients safe. We do not wish to see or hear of other families having to endure the grief, unimaginable loss and anguish that we have been through.
“Not only was Beth bright and vivacious, she was intelligent, had a ‘can do’ attitude and her infectious smile would brighten anyone. She was an accomplished yacht and dinghy sailor who was always full of energy and had a wonderful sense of humour.
“Beth tried to help others through describing her own mental health experiences in a highly graphic but articulate way and by doing so was able to touch and help countless others. We know for a fact that she saved at least one person through her social media presence. That is a huge legacy for a young lady to leave behind.
“Beth gave a bright light of hope to people who were struggling to see any light at all.
“May she now rest in peace.”
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Read our previous reports from the Beth Matthew's inquest:
