Police and the ambulance service have identified 'valuable learnings' after an 'intelligent and caring' mum-of-two was found dead at her home in Tameside where they had been called two days earlier, an inquest has heard.
The body of retired carer Jane Simeone, 48, was discovered when police broke into her house on Egerton in Mossley in November 2021.
She was found to have died as a result of 'combined drug toxicity' from a number of prescription medications. Two days earlier, a concerned mental health practitioner had rung 999 due to concerns over comments she had made over the phone.
Police officers and paramedics attended and spoke to her through an upstairs window. However, she wouldn't let them in and the officers concluded they had no power to force entry.
At a three-day inquest into her death, a coroner said it 'could only ever be speculated' what mental health assessments would 'even conceivably have concluded' had they persuaded her to allow them in.
And he ruled the incident didn't cause or contribute to the death of Mrs Simeone, who was seen alive the following day. However, following her death, the case was referred to the police watchdog the Independent Office for Police Conduct (IOPC) who carried out an investigation into the actions of the GMP officers, with the North West Ambulance Service (NWAS) also carrying out an internal review.
And the hearing was told they had both 'identified valuable learnings' which will shape how they deal with any similar incidents.
Mrs Simeone was an 'intelligent and caring person' who was also 'determined and very social' her mother Susan Lloyd told the inquest. However, she also said she was someone 'who had a tormented mind' and that her behaviour could be 'challenging.'
Mrs Simeone was 'intelligent and caring' but had 'tormented mind' mum says
The hearing was told she had been diagnosed with Emotionally Unstable Personality Disorder (EUPD). Whilst she also had a number of health conditions having previously undergone surgery for breast cancer and she considered herself to have multiple sclerosis (MS) despite having no formal diagnosis with her doctor saying she had chronic fatigue syndrome and features of fibromyalgia.
By 2021 she 'regarded herself as someone with ever-increasing pain and mobility problems' and 'experienced significant stress as a result of what she perceived as an absence of support and increasing financial difficulties' Area Coroner Chris Morris told South Manchester Coroner's Court in Stockport.
"Threats of self-harm and or threats of suicide were a consistent feature' of her illness he said but he said there was evidence these were sometimes believed to be attempts to prompt a response from agencies.
The police and paramedic attendance in the early hours of November 24, 2021, followed a call to the Safe Haven mental health service the previous evening.
Mr Morris said he was 'entirely satisfied' that officers didn't believe they could force entry 'without the specific agreement of Mrs Simeone.'
A friend of one of her sons saw on the day of November 24 when he came round to fix a light fitting and said he was 'concerned' about her and phoned a family member to let them know.
She was found to have died after a call from a friend reporting concern for her welfare on November 26 following which police forced entry.
Coroner said he was unable to say what her intentions were
A post-mortem concluded she died as a result of 'combined drug toxicity.' All the drugs found in her system were prescription medications, with no illicit substances discovered. A police investigation concluded there was no evidence of any suspicious circumstances or third-party involvement in her death.
Ms Lloyd said she did not believe her daughter took her own life intentionally as she was planning to go on holiday and order herself a new sofa.
Concluding the hearing on Wednesday (February 22), Mr Morris said he had to consider: "Was it an accident by someone experiencing painful problems with their physical health? Was it an attempt to get further support gone wrong? Or was it an attempt to bring about her death?"
However, he said: "I simply cannot draw conclusions, even on the balance of probabilities, on these facts." 'Whilst she voluntarily ingested the medication which caused her death' he said the evidence before the court meant he could not be satisfied 'as to her intentions in this respect.' He recorded a conclusion that her death was drug-related.
Following the hearing, an IOPC spokesman said: "We began our investigation in November 2021, which concluded in June 2022, following a mandatory referral from the force.
"We found no evidence to suggest that GMP officers may have caused or contributed to Ms Simeone’s death.
“IOPC investigators did identify a range of organisational learning which included a reminder to all officers that a care plan should be submitted on every occasion where the force responds to a person presenting with mental health-related concerns without exception and a process of monitoring and dip-sampling to ensure the quality of care plans.
“We have also highlighted that police officers and front-line police staff should be made aware of the Mental Health Tactical Advice Service (MHTAS) based within the control room and the force should consider proactively involving the Mental Health Tactical Advice Service (MHTAS) at the outset of a high/medium risk mental health-related incident.
"An inquest held this week concluded with the Coroner recording a conclusion of a drug-related death. During our investigation, we reviewed calls to GMP and incident logs, witness statements were obtained from the officers and paramedics who attended, and GMP’s policy and procedures were analysed.”
GMP said: "We accept the findings of the coroner and whilst there was no criticism of GMP made throughout the hearing, we can confirm that our police officers are educated on both care plans and the Mental Health Tactical Advice Service (MHTAS) that sits within the force's contact centre. GMP endeavours to ensure all officers on the front line follow these procedures at all times."
An NWAS spokesman said: “As a result of this incident, we completed an internal clinical review, which fed into a broader programme improving resources, education and training which now better supports patients with mental health issues. We’d like to offer our sincere condolences to Jane’s family at this difficult time.”
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