A blogger who died after ingesting a toxic substance she purchased online while under the care of mental health services died due to neglect, an inquest has concluded.
Beth Matthews, 26, died on March 21, 2022 , after collapsing in front of staff members at The Priory Hospital Cheadle Royal where she was a patient after being detained under the Mental Health Act.
Jurors at the inquest of the young woman have now found that neglect by staff at the hospital contributed to her death by suicide.
Beth had told ward staff the substance she received in a package from Russia was protein powder, before ingesting it and entering cardiac arrest.
She was rushed to Wythenshawe Hospital, but was pronounced dead shortly before 4pm that day.
The inquest previously heard how a ‘clear direction’ on Beth’s care plan said she should not be allowed open her own mail.
This restriction was also repeated in handover notes relating to her.
However, an internal investigation by The Priory, where Beth had been transferred for specialist therapy, found "inconsistencies" in staff’s approach, with some allowing Beth to open her own post.
On Wednesday, the penultimate day of the nine-day inquest, The Priory Group admitted in a statement that Beth’s care plan "was not followed" as it should have been on the day of her death.
They accepted that "on the balance of probabilities 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".
The mental health blogger had acquired a large following on social media, where she discussed a "Failed suicide attempt" in 2019, the Manchester Evening News reports.
Beth, who was from the village of Menheniot near Liskeard in Cornwall, was described as a "caring, intelligent and articulate" daughter by her mother, Jane Matthews.
Assistant coroner Andrew Bridgman asked jurors to consider whether Beth’s suicide was contributed to by neglect, failure to follow her care plan, or by any other factor. Directing them, he said any finding of suicide contributed to by neglect would have to amount to a "gross failure".
Beth’s medical cause of death was ruled to be 1A) Methemoglobinemia caused by 1B) "poisoning" of the substance. Priory director of risk management David Watts told the court on Monday (January 16) that the group were aware of a growing trend of suicides using the substance, and had issued staff bulletins highlighting its risks in 2018 and 2020.
Throughout the inquest, the court heard detailed evidence of Beth’s history with mental health problems. She was diagnosed with Emotionally Unstable Personality Disorder (EUPD) in 2018, which led to having recurring thoughts of wanting to end her life, the hearing was told.
In April 2019, she suffered "severe" injuries in a "failed suicide attempt after jumping from a bridge" leaving her with "sgnificant long-term pain and disability".
She spent several months in hospital before being transferred to the Fletcher Ward, a psychiatric unit at Bodmin Community Hospital in her home county, from where she was discharged in September 2019.
Following this, Beth set up her blog ‘Life Beyond the Ledge’, in which she documented her experiences as a "suicide survivor" in graphic detail.
But in 2021 her mental health deteriorated again, and after a further stay on the Fletcher Ward, in November of that year, she was transferred to the Fern Unit, a specialist unit for women with her condition at The Priory Hospital Cheadle Royal in Heald Green.
The court heard that the upcoming three-year anniversary of her previous suicide attempt, as well as a recent break-up with her long-term partner Matthew Parkinson, the possibility of being transferred back to Cornwall, and a looming tribunal to challenge her section, were all factors likely to have had a "negative" impact on her mental health in the lead-up to her death.
Analysis of her mobile phone showed during her time at The Priory, Beth made ‘"requent" internet searches relating to the substance she ingested, especially during the two-week period prior to her death.
She also accessed online forums discussing suicide, and told a mental health nurse just weeks before her death that "there are things you can purchase that can do the job".
When pressed, Beth told the carer "it's already done now," and refused to expand further on her comment.
Beth's consultant at The Priory said this should have been raised with him but that she was on the highest risk level at the hospital already and as a result should not have been opening her own mail.
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