Failures by a London NHS Trust to provide adequate mental health support to a woman who took her own life contributed to her death, an inquest has concluded.
Michelle O’Neill, a 54-year-old domestic abuse support worker from Eltham, took her own life on February 28, 2020.
At an inquest held at East Sussex Coroner’s Court last month, HM Assistant Coroner Michael Spencer concluded that Ms O’Neill was “passed from pillar to post” within Oxleas NHS Trust, and that no one had “taken responsibility for her care in the medium to long term”.
This resulted in her “slipping through the cracks”, the inquest heard.
In his final ruling, the Coroner remarked that “it is difficult to describe the service she received from the Oxleas Trust in the year preceding her death as anything other than disjointed and reactive”.
He added that “proper long-term care coordination, with appropriate therapeutic intervention, would have made a difference to the outcome for Michelle”.
Oxleas NHS Trust said it was “very sorry that this tragic incident happened” and that it had “reviewed and made changes to the way patients move through our services” in the wake of Ms O’Neill’s death.
Ms O’Neill experienced her first mental health crisis in March 2019, almost a year before her death.
Over the following year, circumstances in her life – including allegations of domestic abuse against a former partner, the financial stress resulting from that abuse and an ongoing investigation against her by the Met Police - had a severe impact on her mental health.
She was admitted to the Millbrook Ward at Queen Mary’s Hospital in Sidcup as a voluntary inpatient in May 2019, but discharged on June 14.
Ms O’Neill’s sister Deborah told the inquest that her family had to keep her under constant watch following her discharge, but that they were unable to keep her safe.
Over the next four months, Ms O’Neill made several attempts to end her life and she was hospitalised again for a month in August 2019.
During the same period, Ms O’Neill was meant to receive support from the ADAPT team, a community service designed to provide long-term therapy for patients with mental health conditions.
But despite the attempts to take her own life from June 14 until her death in February 2020, Ms O’Neill was discharged from the ADAPT team three times without ever receiving an assessment or therapy.
She was also repeatedly discharged from other community services, including the Home Treatment Team (a crisis service) and a counselling service called Greenwich Time To Talk, without ever receiving counselling nor being seen by a psychologist or a doctor.
‘Repeatedly discharged without therapy’
In January 2020, Ms O’Neill was re-referred to the Trust’s Primary Care Plus Team by her GP, who felt her medication was insufficient to control her symptoms.
During telephone conversations with the team, she was noted to be “very, very manic”.
The inquest heard expert evidence at this point that, at this stage, she should have been provided with an urgent appointment and assessment. Ms O’Neill herself requested that her next appointment be brought forward – but it was pushed back a month by the Trust.
The Coroner identified this as a “missed opportunity to assess, identify and take steps to mitigate Ms O’Neill’s risk to herself”.
Ms O’Neill went missing on February 16, 2020 after travelling to Hove and making an attempt to take her own life.
The Met Police notified Oxleas NHS Trust of the incident and Ms O’Neill was considered to be “high risk pending further assessment”.
A nurse tried to make “urgent contact” with Ms O’Neill and left voicemails for her as well as her family members.
Ms O’Neill returned the nurse’s call 15 minutes later and was put through to her voicemail.
However, the nurse did not retrieve the voicemail nor make further attempts to contact Ms O’Neill.
The nurse told the inquest that she assumed Ms O’Neill was safe because she was with her family.
But the Coroner identified the failure to urgently assess Ms O’Neill at this point, or put in place any measures to mitigate the risk to herself, as a further missed opportunity on the part of the Trust to provide effective healthcare to Ms O’Neill.
‘Missed opportunities’
Twelve days later, Ms O’Neill went missing for the final time and her family notified police that she was likely to go to the coast to take her own life.
That evening, a woman was seen acting strangely on rocks by the beachfront at Hastings during Storm Jorge - but a later search by Sussex Police was unsuccessful.
Ms O’Neill’s body was located the next morning on Camber Beach.
The Coroner concluded that it was likely that the woman seen on the rocks was Ms O'Neill and that she had entered the water in Hastings.
Ms O’Neill’s son Connar Higgins, her twin sister Janet O’Neill and her elder sister Deborah O’Neill, said: “Michelle had helped so many others throughout her life, but when she asked for help herself she was consistently denied any meaningful assistance, which added to her suffering.
“It has taken far too long to reach this point but we are rightfully glad that the Assistant Coroner has made critical findings against Oxleas NHS Trust.”
Hayley Chapman, Solicitor at Hodge Jones and Allen, which acted for the family, said: “It is dismaying to see how a woman in Michelle’s position kept asking for help, but was repeatedly discharged without receiving any therapy, care coordination or proper recognition of the risk she posed to herself.
“It is right that the Coroner has recognised the seriousness of the Trust’s failures in Michelle’s case. Michelle’s family have fought for three years to get to this point, and we hope that during this time lessons have been learned so that no other family has to suffer like they have.”
Abi Fadipe, Medical Director at Oxleas NHS Foundation Trust, who gave evidence at Michelle O’Neill’s inquest, said: “We were deeply saddened by Ms O’Neill’s death and would like to again express our sincere condolences to her family at this difficult time.
“We have reviewed and made changes to the way patients move through our services to ensure support continues smoothly when care moves to a new team.
“We have also, in line with NICE guidelines, adopted the use of safety planning in collaboration with our service users. Staff have completed training on risk management and are being supported to implement this with mentoring and coaching from more experience colleagues.”
She added that the Trust “fully” took on board the points highlighted by the Coroner and was “very sorry that this tragic incident happened”.
