Inquest Finds NHS Trust Could Have Done More To Prevent Suicidal Woman’s Death

By Suzanne Rutter

The family of a woman who committed suicide after repeatedly warning her doctors and loved ones she wanted to take her own life have vowed to continue battling for answers amid concerns about the care she received in the weeks before her death.

Jane Hallam, of Woodhouse Mill in Sheffield, voluntarily admitted herself to the psychiatric ward at the Northern General Hospital in Sheffield on 6 April 2011 after telling her family, a friend and her GP on three occasions that she planned to commit suicide.  This was the first time Jane had required hospital treatment for mental health issues.

The 61-year-old was discharged three weeks later on 27 April into the care of the Crisis Resolution and Home Treatment Team (CRHT), run by Sheffield Health and Social Care NHS Foundation Trust, despite advising doctors the day before that she did not feel ready to go home.  

She made another attempt to take her life just a day later. She was readmitted to the medical assessment unit at the Northern General but was discharged again days later despite her family pleading with doctors to keep her in for further observation.

The community-based Crisis Resolution Home Treatment Team (CRHT) took over care for the mum-of-two in the following weeks but there was a lack of adequate support and she was found dead at her home on 17 May. Her death came just a day after she had been seen by a consultant psychiatrist at the trust who allowed her to go home, despite her reporting that she had been thinking of committing suicide in the consultation.

Lawyers at Irwin Mitchell representing the family in their battle for answers from Sheffield Health and Social Care NHS Foundation Trust say they remain ‘seriously concerned’ about the care Jane received in the weeks leading up to her death.

An inquest heard by Mr Geoff Saul, HM Assistant Deputy Coroner for South Yorkshire East District, concluded today at Doncaster Coroner’s Court and recording a narrative verdict. He said: “The decision to allow her to return home, albeit with some protective measures, probably did contribute in part to the tragic outcome.”

Laura Craig, a medical negligence lawyer at Irwin Mitchell’s Sheffield office representing Jane’s family said: “Jane was a loving mother and grandmother who had turned to medical professionals for help in early March 2011 after she began feeling severely depressed and anxious. Because of the recession she became obsessively worried about losing her job at HM Revenue and Customs as cuts were taking place and she feared that she would be unable to cope financially as a single woman.

“In the weeks leading up to her death she continued to display odd behaviour and talked about taking her own life. But despite the warning signs and repeated pleas from her worried family, the trust failed to re-admit her between 1 May and 16 May so she could be monitored more closely.

“The inquest has helped answer some of the many questions Jane’s family have about the care she received between April and May 2011 but they remain seriously concerned about whether more could potentially have been done to prevent her tragic death. We will continue to help them in their battle for justice.”

The inquest heard how Jane’s mental health deteriorated rapidly between early March and May 2011 and she saw her GP three times before she was admitted to the Northern General Hospital on 6 April 2011.

She was discharged after three weeks into the care of the Crisis Resolution and Home Treatment Team but the care she received was disjointed and on one occasion the team failed to find her address and abandoned their visit to see her.

A further suicide attempt meant she was readmitted to hospital again on 28 April and discharged three days later on 1 May against her family’s wishes.

In the following two weeks, between 1 and 16 May, her health continued to deteriorate and she continued to express suicidal thoughts to the crisis team and to her family. However, she was not readmitted for further in-patient care. On 16 May she was reviewed by a trust psychiatrist, where she again expressed suicidal thoughts but was sent home and deemed fit to look after herself. She hung herself at home on 17 May 2011.

An internal investigation carried out by the trust following Jane’s death raised a number of concerns relating to failures in the system such as poor record keeping, lack of communication amongst staff and poorly completed risk assessments which may have contributed to her death.

Pauline Hallam, Jane’s sister-in-law, of Richmond in Sheffield, said: “The whole family have been overwhelmed by Jane’s death and it has been extremely difficult to come to terms with, particularly as we have been very concerned about the standard of care she received.

“We trusted the professionals to look after her but we strongly believe neither Jane nor us were properly listened to and her threats to take her own life were not taken seriously enough.

“We are grateful to the coroner for taking our concerns seriously but we are determined to find out if more could have been done to save her. We also want to ensure that other families don’t have to go through similar ordeals in future and any important lessons that can be learnt from Jane’s case are implemented by the trust.”

Irwin Mitchell’s Laura Craig confirmed that a civil claim was being pursued against Sheffield Health and Social Care NHS Foundation Trust to provide the family with further answers about the events in the lead up to her death.

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