The family of a young Bristol woman have expressed their devastation after she took her own life while she was being looked after at a mental health crisis house. Jess Durdy died aged 27 while she was under the care of Bristol-based charity Missing Link, and a coroner's inquest has found that she died by suicide.
But Jess's family have criticised the charity and NHS mental health services over her death, which they feel was 'preventable'. Jess moved into Link House on October 11, 2020, and five days later she took her own life.
Jess's mum, Moira, expressed her 'profound and endless' grief at their loss following the verdict of suicide from Dr Peter Harrowing at Avon Coroner's Court.
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If you are struggling with your mental health, you can call Samaritans for free on 116 123, email them at jo@samaritans.org, or visit www.samaritans.org to find your nearest branch
"A light has gone from our lives, and we will miss her forever," said Moira. "She tried so hard to get the help she needed, but the mental health services provided by AWP [Avon and Wiltshire Mental Health Partnership NHS Trust] did not function for her."
Jess, who grew up in North London, studied at the University of Bristol before moving to the West Country city permanently in 2016. According to INQUEST, a charity which provides expertise on state-related deaths to lawyers, Jess was referred to Link House by the AWP because she was struggling with daily suicidal thoughts that were becoming increasingly intense and intrusive.
Lawyers for her family have argued that Jess did not get the proper support from Avon and Wiltshire Mental Health Partnership (AWP), or from Missing Link. The coroner's court heard evidence from Jess’s counsellor that she had spoken out about which method of suicide she was most likely to use, and it was this method with which she took her own life.
However, according to INQUEST, no one at AWP or Link House asked Jess about this, and staff at Link House had not been informed by AWP that Jess had previously attempted to kill herself. Jess reportedly told staff at the house that she was having very strong urges of ending her life on three consecutive days.
Lawyers questioned staff training and claimed they had not recognised the difference between suicidal thoughts and suicidal plans. Staff reportedly attempted to contact the Recovery and Crisis Teams but did not follow up on these calls when there was no response.
On the day that Jess died, her door was found locked and staff rang 999, but an ambulance took 30 minutes to arrive. And according to INQUEST, Link House staff were not trained in making emergency calls and did not use the "buzzwords" to trigger a more immediate 'Category 1' response, rather than the less serious Category 3 response it provoked.
Staff were unable to enter her room, and INQUEST say that "this apparently could not have been avoided, even if the nature of the emergency had been better communicated," because no one could get in to tell the ambulance if Jess was breathing - the necessary trigger for a Category 1 response.
An INQUEST statement said Jess’ death was "entirely preventable", and it criticised the oversight from the AWP as well as the alleged failings of Link House. The statement called for action and said they feel there has not been sufficient change at the facility since Jess died.
INQUEST said there is "increasing use of voluntary sector crisis houses across the UK" by mental health trusts, and they are concerned that the tragedy could be replicated elsewhere. Its statement continued: "With clinical oversight comes regulation, which is something that had been completely lacking at Link House."
It also claimed there was no audit of the premises, and that there was a need for more independent oversight of procedures in place and "checks to ensure that staff are appropriately qualified and trained to work with vulnerable women like Jess".
'Avoidable deaths will continue to happen'
Following the verdict, Jess's mum Moira said that because of the 'failures' of the AWP and Link House, her family 'have lost the daughter and sister we loved so much'.
"She had asked sensible questions in order to understand the newly prescribed medication which could have helped," she said. "These were not answered, and so the opportunity of pharmacological intervention was lost.
"Once at Link House, staff from AWP had no further direct contact with her. She was left in the care of the junior support staff who worked there, who had received no recognised training in risk assessment."
Despite desperately informing the support workers on three successive days how frightened her daughter was by her intrusive thoughts of taking her life, she claims no meaningful action was taken to assess her risk, keep her safe at Link House or to request professional help from AWP. She also criticised the coroner's verdict, accusing him of failing to adequately criticise the AWP's clinical oversight and risk management.
Jodie Anderson, senior caseworker at INQUEST, also echoed these concerns. "It is only through the sheer determination of Jess’ family to have her voice heard through the process that the extent of systemic failings was truly exposed in a highly critical Serious Incident Investigation. We do not believe the inquest conclusion reflect these failings.
"We see in Jess’ case yet another lost opportunity to prevent future deaths.” Avon Coroner's Court has been approached for comment.
Moira also added that she is "disappointed by AWP’s lack of acknowledgement of the things that went wrong, and by their legal representatives' continued attempts during the inquest to halt relevant questioning, with a complete lack of regard to the effect this has had on those most devastated by the loss of Jess".
Lawyers for the family have raised concerns about the use of Link House to treat women like Jess. Gemma Vine of Ison Harrison Solicitors, who represented the family, said: “Psychiatrists have been raising the alarm on the national shortage of mental health bed spaces for years but it has only got worse through the pandemic.
"Voluntary sector crisis houses are increasingly used as an alternative to inpatient care, but whether a patient will get the necessary clinical support throughout their stay is a postcode lottery. Tragically, Jess was left in a place where staff did not have the requisite training to identify the obvious risk to her life.
"Even the Trust struggled to understand who retained overall responsibility for Link House despite it having been a commissioned service since 2009. Jess’ family have tirelessly worked to understand and evidence these failings to ensure it does not happen to anyone else in the future. Without proper regulation and oversight, avoidable deaths will continue to happen.”
And Jess’s dad, Ken, said that he doesn't think Link House is a 'safe place' for women with mental health issues. “Sadly Jess hid her illness from those that loved her most and chose to put all her faith in mental health professionals," he said.
"NHS mental health teams should not be transferring care for those in escalating crisis from the hands of qualified and registered staff to the mercy of the unqualified staff where there are unregulated systems of care in place like at Link House." Missing Link and the AWP have both been approached for comment.
Dr Sarah Constantine, medical director at Avon and Wiltshire Mental Health Partnership (AWP) NHS Trust and Sarah O'Leary, CEO of Missing Link in a joint statement, said: “We offer our sincere condolences to the Durdy family.
"Both organisations recognise that the Coroner conducted a detailed investigation into this case. His finding that Jessica was properly supported throughout the time she was under the care of AWP and in the care of Missing Link's Link House Service does not detract from the fact that any life lost to suicide is a tragedy.”
If you are struggling with your mental health, you can call Samaritans for free on 116 123, email them at jo@samaritans.org, or visit www.samaritans.org to find your nearest branch
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