A woman who was described as ‘the life and soul of the party’ was discovered dead after her mental health worker failed to visit her at home.
Scarlett O’Malley, who was a nursery nurse, had been diagnosed with emotionally unstable personality disorder and was known to mental health services for over a decade.
Her treatment was overseen by a care coordinator who failed to visit her when she was supposed to and instead left her a voicemail.
An inquest into the 27-year-old’s death has heard Scarlett sent an image to her brother Levi, implying that she was considering suicide on April 19 2021.
Police visited her home where they found Scarlett dead after her body was discovered by Levi.
The inquest heard that Scarlett, from Blackburn Road, Accrington, began receiving treatment from mental health services in August 2011 after she was taken to A&E by her family following an incident of self-harm and attempted suicide.
Scarlett’s relatives had been forced to physically restrain her to prevent her from jumping out of a window, according to Lancashire Live.
Ewan Cole, the patient safety lead at Lancashire and South Cumbria NHS Foundation Trust - which provides mental health services - carried out an investigation after Scarlett’s death.
He reviewed her notes and said Scarlett had told doctors about traumatic events from her past and a number of difficult relationships, “particularly with family members”, but she was hopeful for the future and was keen to be happy and manage her mental health.
The inquest heard Scarlett took part in group therapy sessions which she said she found helpful and she also regularly called the mental health crisis line as well as the Samaritans.
On Monday, April 19 last year Scarlett’s mum Kate contacted her daughter’s care coordinator, Rebecca Brown, and “expressed concerns”.
She said Scarlett had been drinking heavily over the previous three days and she had sent a picture message to her brother Levi which indicated she was considering suicide.
Levi told the coroner’s court: “I immediately contacted my sister and then my mother.
“I explained I was at work in Bury, my mother contacted Scarlett’s care coordinator Rebecca Brown who said she would make contact with Scarlett and if she couldn’t she would attend her house.”
However, the inquest heard Ms Brown did not visit Scarlett, and only left a message on her voicemail.
Mr Cole said Ms Brown had been concerned enough to consult her manager but they considered that the action taken “was felt to be a proportionate plan”.
“What my investigation found is that it wasn’t,” he said.
“Somebody could have gone out. There were ways in which somebody could have gone out that day.
“She had sent the picture, so that would worry me, and that is an indication that somebody is at risk and given Scarlett’s history of harming herself when she was distressed our view was that that should have warranted a different response.
“I think Scarlett needed to have been seen that day and according to her care plan that’s what should have happened.”
Scarlett’s mum Kate said that she felt reassured that Ms Brown would visit her daughter.
“But she didn’t do anything,” she said.
“If Rebecca had called me back and told me she wasn’t going to visit Scarlett then I would have done, like we have done on every single other occasion, apart from this one.”
Levi told the inquest he suffers from post-traumatic stress disorder as a result of finding his sister dead at home the following day on April 20.
“I no longer sleep anymore... I can’t open doors,” he said.
The inquest heard Scarlett had a significant amount of alcohol, and some cocaine, in her system at the time of her death. The cause of death was recorded as compression of the neck.
Scott Smith, associate director of community mental health teams at Lancashire and South Cumbria NHS Foundation Trust, said that while national guidance stipulates a patient should be visited within 24 hours of an “urgent crisis event” Scarlett should have been visited sooner.
“We’ve made sure that we don’t miss opportunities again and lessons have been learned,” he said.
“Any pictures or suggestions around ligatures that might indicate a future risk, we have held a number of different learning events and we have introduced it as almost a blue light warning. We have a system which is an alert to all teams to say that if there are any indications of imminent risk or ligatures then the necessary precautions need to be taken. That was done very swiftly.
“We have also done lessons with the individual team and practitioners.”
Scarlett’s mum said: “It’s such a shame that a young girl had to lose her life in order for that to happen.”
Recording a narrative conclusion, Area Coroner Richard Taylor said: “Scarlett was troubled, she needed help, she was getting some help and it seemed to be working but there were signs that things weren’t working again.
“On April 19 it is quite clear that an opportunity was there and wasn’t taken to go round to Scarlett’s house to see her. I have no doubt that that should have happened.
“To find that somebody has died by suicide I have to find that they have done a deliberate act but I also have to find that she does that with the sole intention of ending her life and this is where it is a bit more difficult.
“She had had a drink and was known to act impetuously.”
In an obituary published online after Scarlett’s death she was described as “beautiful, glamorous and always dressed to impress”.
“Scarlett was the life and soul of the party and wherever she went her larger than life personality would light up the room,” the tribute read.
“Scarlett was the most devoted nursery nurse and adored all the children in her care. Her work saw her travel to America and Australia.
“With her caring and giving nature Scarlett had set her sights on becoming a counsellor which she was training very hard towards. She loved holidays and many happy times have been spent enjoying time away with family and friends.
“An avid horse fanatic Scarlett loved to be out in the open air enjoying nature. She was the most doting and proud auntie to Rio and Rudy who always looked forward to spending time with her on their many walks and visits to the park.”
Lancashire and South Cumbria NHS Foundation Trust’s director of governance, Stefan Verstraelen, said: “We accept the findings and recommendations of the Coroner during the inquest of Scarlett O’Malley and would like to offer our sincere condolences to her family at this incredibly difficult time.
“We acknowledge that the plan of care was not aligned to the crisis contingency care plan that had been developed with Scarlett and this meant a missed opportunity to implement alternative interventions.
“Improving patient safety is of utmost importance to us and at the heart of what we do. Following Scarlett’s death, we launched a thorough investigation, which identified recommendations and learning, so we could improve the service we offer. Since then, we have continued to implement changes to avoid a similar incident.
“Our thoughts remain with Scarlett’s family.”
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