Mental health practitioners did not believe a mum-of-one posed a 'significant risk' to herself in the days and weeks leading to her death, an inquest has heard. Kate Hedges, 35, passed away at Gatley train station in November 2020 having been released from hospital in October and referred to the home based treatment team.
Kate had been described as a 'beautiful and bright person' at an inquest into her death on November 27 2020 at South Manchester Coroners Court. She had long suffered with mental health issues after significant trauma when younger, including being bullied at school and raped when she was 19. She also cared for her young son who has autism.
Her family yesterday raised further concerns that they were not involved in Kate's care and were not regularly consulted by both the hospital ward and home based team she was discharged into. Day two of the inquest in Stockport heard how doctors at the Bronte ward at Wythenshawe Hospital, where Kate was being treated after being sectioned under the Mental Health Act, felt her condition had improved enough for her to be discharged to the home based treatment team. This is despite earlier 'manic behaviour' on this ward and Kate going missing when granted unaccompanied leave.
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During her time at Wythenshawe Hospital Kate was diagnosed with bipolar disorder, which she didn't accept at first, before her mental state gradually improved. The court heard yesterday from Dr Muhammad Imran, a consultant psychiatrist at Wythenshawe Hospital, that from her admission on September 9 to his last interaction with her on October 20, she had become calmer, but he did not believe she was ready to be discharged.
Despite this, on October 27, following a consultation with Mr Jon Lysons - a mental health practitioner with the home based treatment team at the hospital - and Dr Muhammad Iqbal - a registrar on the ward - it was determined that Kate's condition had improved enough and home based treatment was appropriate for her. Mr Lysons said Kate was finding the ward environment 'distressing' but she was very calm when he spoke to her.
Mr Lyons said he "did not have any concerns she was not ready" for home based treatment and that it would be the best place for her. Dr Iqbal led the discussion with Kate around discharging her to the home based treatment team, agreeing her condition had 'improved' in the weeks leading to October 27.
"Kate was very much involved and engaged in the conversation," he told the court. "She expressed herself and said she felt much better." Dr Iqbal added she was no longer displaying any psychotic symptoms that had led to her sectioning and that the legal justifications for her detention were no longer warranted.
It was discussed with Kate about staying in the hospital voluntarily but she was keen to return home as the ward can be an 'intense' and 'detrimental' environment. Dr Iqbal said Kate was responding well to her medication and she wanted to be back at home with her young son.
"We concluded that discharging her with the home based treatment was the most appropriate step at that time with Kate involved with decision and agreeing to it," Dr Iqbal added. Kate returned to her home in Burnage and would soon move to Gatley.
Andrew Barron, a mental health practitioner from Greater Manchester Mental Health's home based treatment team, first started meeting with Kate at her home every other day on October 30. He said her mental state appeared 'settled'.
"She was motivated to do things and was hopeful for the future," he also said she had a good support network of friends and family in place. He added that they would not reach out to the family as par of the course as an adult with no immediate safeguarding concerns.
Kate continued to improve over their meetings, Mr Barron said, and despite moving homes was coping well. Matthew Baron, representing Kate's family, raised concerns that Kate's family were not involved in discussions with the home based team about their treatment. Kate had told Mr Barron she had a 'strong support network' and that because of this the home based treatment team 'would not normally get involved' with the family unless there were immediate safeguarding concerns.
After their last meeting on November 6, Jacqueline Cox, another mental health practitioner, became Kate's named worker, meeting Kate for the first time on November 14. At this point Kate had been moved into 'green' on a traffic light system as her condition improved, having been on 'amber' when first discharged, meaning she was visited less frequently by a practitioner.
Ms Cox described Kate as very 'pleasant and warm' when they first met. Kate had been very positive about the move from Burnage to Gatley and her mental state was good.
Area coroner Christopher Morris told Ms Cox about evidence from Kate's sister, Maya Hedges, told to the court yesterday (April 19) about how Kate became 'withdrawn' and 'didn't know who she was anymore' after this move. Ms Cox did recall that Kate told her she was 'bored' and wanted to get back to work. She was also frustrated at not being able to drive and Ms Cox helped Kate come up with plans to validate these frustrations and overcome them.
"I didn't feel there was any escalation of risk and I wanted to help her achieve her goals," Ms Cox said. Kate did say she had begun feeling a bit low but was still planning for the future with her son and didn't talk of harming herself which reassured Ms Cox.
At the next meeting Kate admitted her medication had made her feel like a 'zombie' at times but Ms Cox still felt there were no risks to her safety or wellbeing at that stage. Ms Cox's last meeting with Kate happened on November 23.
"She reported an improvement with taking less medication and had spent time with her family and strong support network," she said. "At that time I did not have any express concerns around Kate's safety or wellbeing but I was still trying to support Kate as best I can with her trying to come to terms with her illness. There were no significant risks in that last appointment."
Kate was set to be slowly discharged to the community mental health team from this point, and had been assigned a worker for this. However, Kate died four days later.
Coroner Morris is set to raise concerns around the 'patchy' communication between the Bronte ward at Wythenshawe - run by Greater Manchester Mental Health Trust - and different mental health services within the trust having different note recording systems. Yesterday Ms Hedge's mother, Nuala Finegan, paid tribute to her daughter saying: "Even when she was unwell, she was very much Kate. She had an infectious laugh and her death had been devastating for us."
The inquest continues.
