A Hebburn woman who had begged to go to hospital to escape voices that were “tormenting” her took her own life after a “compromised” assessment recommended treating her at home.
Rachel Shaw, 31, died in the Freeman Hospital on September 7, 2020, after falling from the Tyne Bridge.
Rachel was suffering from schizophreniform disorder , Newcastle Coroner’s Court heard on Wednesday. She had been sectioned in June after her first psychotic episode, spending 20 days in hospital before being discharged for treatment in the community.
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After returning to her Hebburn flat, Rachel was cared for by the Early Intervention in Psychosis team. She was initially prescribed antipsychotic medication olanzapine, but asked to change drugs after suffering side effects. She was moved to amisulpride, but after 10-12 days it began to cause “anxiety and panic attacks”.
In a bid to address these symptoms, the team’s consultant psychiatrist proposed moving her onto a third medication, respiridone. Care coordinator Vanessa Bouchard dropped off a prescription for the drug at Rachel’s home on Friday, August 28, but due to the bank holiday weekend she was unable to collect the medication.
The mental health nurse, who was on a week’s annual leave at the time of Rachel’s death, said she had believed her patient was taking her medication correctly and was at low risk of harm.
She said: “I felt at the time that Rachel presented quite low-risk, she seemed quite stable on medication, she was looking forward to going back to work, in terms of future planning she was looking for a bigger flat."
She said there had been no reason to think Rachel wasn't taking her medication as her condition seemed to be stable, and she had been honest about difficulties with her previous medication which led to it being changed.
On August 30, Rachel suffered another psychotic episode and contacted the local crisis team, who arranged for treatment at home, which lasted until September 3.
But in the early hours of September 6 both Rachel and her stepmother contacted the crisis team as her symptoms worsened.
She was described as "floridly psychotic", suffering from both visual and auditory hallucinations. Rachel’s father Peter Shaw said his daughter had told him that "voices and visions were focusing on death as the only way she could escape this torment".
After the early morning calls, two nurses from the crisis team arrived at Rachel's parents' home, where she was staying.
When they arrived, Mr Shaw said: “We made it clear that Rachel’s symptoms were more severe than her first episode and that she was having visual and audio experiences and she was talking about her own death as the only way to escape the torment.
“As parents we explained we were completely out of our depth with regard to the severity of this episode and that we were concerned that Rachel was expressing death as an escape... She talked about returning to [psychiatric ward] Longview as the only way to be safe from the voices.”
However, psychiatric nurse Stephen Holt told the court that Rachel had been assessed as not requiring hospital treatment and it had been decided to prescribe her drugs to help her sleep and to provide at-home care from the crisis team, with admission an option if her condition got worse. He said she had been assessed as not presenting an "immediate risk of suicide" because she'd spoken about death as an escape, as opposed to expressing an active plan.
He said: "Although hospital does serve its purpose it's not the best resource in all cases. It was felt in this case, especially given she had responded well to home-based treatment in the past, that we could try and address the sleep issues to see if it did alleviate the symptoms - I'm not saying it would have stopped them but it might have made them more manageable for her and her family. Also, we could effectively monitor the medication that Rachel was prescribed, and if while doing that home-based treatment the risk changed we could always review the plan."
However, that evening, after telling her family she wanted to go back to her flat to get a good night's sleep, Rachel was seen on CCTV walking along the Tyne Bridge and then jumping into the water.
Newcastle Senior Coroner Karen Dilks said the assessment of Rachel on September 7 was "compromised" in a number of ways.
She said there was "a failure to give sufficient weight, if any, to the views of Rachel and her parents" on hospital admission; as well as to give sufficient weight to her "florid psychosis" and her "belief that death was the only way of escape".
Notes from the other crisis team nurse, David Hetherington, had said that Rachel had only previously been hospitalised for four or five days, as opposed to 20. Mrs Dilks said this "erroneous" belief had also compromised the assessment.
Mr Holt had also claimed that the crisis team had accessed Rachel's medical history and notes before commencing the assessment, but Ms Dilks said the evidence heard at the inquest along with online records had not shown evidence of a comprehensive review of Rachel's records before meeting her.
The Coroner stopped short of saying these failings were a direct cause of Rachel's death, but ordered mental health trust Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust (CNTW) to "learn" from the issues highlighted in her care. She recorded a narrative conclusion, saying that Rachel "died from her own actions whilst suffering from schizophreniform disorder".
At the opening of the inquest, Mr Shaw told the coroner: “Our only want is to ensure that what we have experienced as a family does not happen to anybody else - we have no desire to see anybody disciplined or losing their jobs.”
Speaking after the conclusion, he said: "Ultimately, we believe that if Rachel had been sectioned she would not have died that night."
Gary O’Hare, Chief Nurse at Cumbria, Northumberland, Tyne and Wear Foundation Trust (CNTW) said: “We would like to offer our sincere and heartfelt sympathies to Rachel’s family and friends at this sad and difficult time.
“The Trust undertook a serious incident investigation following Rachel’s death to identify issues or concerns, and the coronial process has also given us the opportunity for care and treatment offered to be further reviewed, and to ensure that the lessons learned are taken forward.”
- For confidential support from volunteers, including for suicidal thoughts, Samaritans can be contacted free, on 116 123 or by email to jo@samaritans.org
- In the North East, If U Care Share Foundation supports those bereaved by suicide and works towards suicide prevention.
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