Coroner Finds an “Unacceptable Delay” In Access To University Mental Health Support
The family of a student who took her own life has called on universities to improve mental health services to stop young people ‘falling through the cracks’.
Ceara Thacker’s body was found in her halls of residence at the University of Liverpool in May 2018 after concerned friends raised the alarm.
The 19-year-old had a history of mental health issues and was known to health services in the city after previous suicide attempts.
Following the death of Ceara, from Bradford, her family instructed specialist lawyers at Irwin Mitchell and Garden Court Chambers to help them gain answers at an inquest.
Ceara’s family, including dad Iain, have now joined their legal team in calling on universities to improve how they care for students with mental health issues.
It comes after Anita Bhardwaj, Area Coroner for Liverpool and Wirral concluded:
• “There was an unacceptable delay of over two months” between Ceara requesting an appointment with the University’s Mental Health Advisory Service (MHAS) and her first appointment.
• “None of the plan” drawn up by the MHAS following their appointment with Ceara in April 2018 was carried out by the time of her death.
• A warden at the university hall of residence “omitted” to contact the MHAS after Ceara report taking an overdose in February 2018 and that this was not “in accordance with policy”.
• It would have been “helpful” if the university had discussed with Ceara contacting her family for support.
• A “follow-up appointment should have been offered” by Ceara’s GP, the Brownlow Hill Medical Centre, after Ceara reported that she was self-harming in October 2017.
• “It would have been appropriate” for the Brownlow Hill Medical Centre to attempt to make contact with the University after it received further information about Ceara’s mental health in April 2018.
The coroner also said that she would be issuing a Preventing Future Deaths report highlighting training for first aiders on how to respond to people found hanged, after a pathologist told the inquest that he was “unsure why Ceara was not cut down” after being found by university staff.
Expert Opinion“Ceara’s tragic death is the latest in a number of deaths involving vulnerable students that we’re seeing.
“Ceara’s inquest has heard evidence of a disturbing litany of failures by various agencies and organisations, including the University of Liverpool and the Mersey Care NHS Foundation Trust.
“It should be noted that these failures have only come to light as the result of a five day inquest and a series of preliminary hearings, something that we campaigned for on behalf of the family.
“It is disappointing that the University of Liverpool instructed a senior barrister to oppose the family’s request and argue that Ceara’s inquest should be limited to one day only. This would have dramatically reduced the family’s ability to get answers to their legitimate questions.
“Thankfully this argument was unsuccessful, but the fact that it was ever advanced calls into question the university’s publicly stated intention to learn lessons from Ceara’s death. The same concern arises from the fact that the University opposed the family’s request for the Coroner to instruct an independent expert to review the care provided to Ceara.
“The university may reflect that the money it has spent opposing the family’s requests in this inquest which could well have been better spent improving mental health services for its students.
“We now call on the university and other institutions across the country to reflect on the circumstances in which Ceara died and to improve the way they support young and often vulnerable adults.” Gus Silverman - Associate Solicitor
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Selen Cavcav a caseworker from the charity INQUEST which has been working with the family said: “It’s a gross injustice that Legal Aid is regularly not made available to families in the same position as Ceara’s when public authorities are represented by lawyers funded by the taxpayer and large institutions such as universities are represented by lawyers paid for out of deep pockets. INQUEST is campaigning for the government to introduce legal aid for all inquests, such as Ceara’s, where state bodies are represented. It’s time to level the playing field for bereaved families.”
Ceara’s father, Iain Thacker, 56, of Guiseley added: “Sitting in the coroner’s court for the last week and hearing about all the ways in which Ceara was failed has been almost unbearable for our family.
“Ceara was a perceptive, intelligent, loyal, funny and extremely kind young woman. She was curious about the world and came to Liverpool to study philosophy and be happy.
“Sadly, when her mental health began to decline she found herself falling through the cracks, with mental health services, her GP and different departments within the university failing to communicate with each other to ensure that she was provided with the support that she desperately needed.
“One crucial source of support could have come from us, her family. For as long as I live I will never understand why no-one at the university picked up the phone to us in February 2018 and told us that our 19-year-old daughter was in hospital after taking an overdose.
“If we had known how Ceara was suffering we could have, and would have, made a difference. We had cared for Ceara and helped her through her struggles with mental illness since she was 13. We thought she was stable and managing her mental health well. Eight months after coming to the University of Liverpool she was dead.
“We all know that student suicides are on the rise. They are a uniquely vulnerable group. No longer children, and not yet adults, often away from home of the first time and facing a host of new stresses and challenges. In my view it is absolutely essential that all universities have in place proper systems for identifying students at risk and communicating effectively with healthcare services and, where appropriate, with families to ensure they are kept safe.
“Although the evidence we have heard during this inquest has often been shocking, we have been grateful to those witnesses who came with an open mind and were willing to admit mistakes and learn lessons. In contrast, our search for the truth was not helped by the University of Liverpool as an institution.
“We are also disappointed that a public apology has still not been forthcoming from either the University of Liverpool or Mersey Care NHS Foundation Trust.
“Ceara was a much loved daughter, sister, step-sister, partner and friend. We miss her every day and we wish that she was still with us.
“We will hold Ceara in our hearts forever. Her memory is a blessing to all who were fortunate enough to know her. We hope that our suffering will not be in vain and that young people in Liverpool and across the country will be safer as a result of the lessons which must be learned from our daughter’s death.”
Ceara joined the University of Liverpool as an undergraduate philosophy student in September 2017 and lived in the university’s Crown Place halls of residence. She was from Bradford and had been under the care of Child and Adolescent Mental Health services as a teenager.
She disclosed details of her mental health difficulties in the disability and special needs section of her UCAS application form, stating that she was “receiving treatment and taking prescribed medication for depression, panic and anxiety”.
The inquest heard that on 26 September, 2017, Ceara telephoned Talk Liverpool an ‘Improving Access to Psychological Therapies’ service operated by the Mersey Care NHS Foundation Trust. She explained that she was “experiencing severe bouts of depression and dissociation and struggling with suicidal and self-harm urges”. Talk Liverpool told Ceara that she needed to register with a Liverpool based GP practice before they could help her.
On 3 October 2017, Ceara attended the Accident and Emergency department of the Royal Liverpool Hospital and told the mental health liaison team that she was “having overwhelming thoughts to harm herself so needed to speak to someone”, that she had been sexually assaulted a year ago, and that “over the last few weeks has been having thoughts to end her life which make her feel "scared”. Staff concluded that there “does not appear to be any indication that input from secondary mental health services is required at this stage” and suggested that Ceara see her GP and seek counselling.
On 23 October, 2017, Ceara attended a GP appointment at the Brownlow Hill Medical Centre. She explained that she was self-harming and was issued with a further 30 days of antidepressant medication. This ran out before her death in May 2018 and she was never offer a medication review.
In November 2017, Ceara was sexually assaulted again whilst on a night out with friends. She later met with the University’s Advice and Guidance team and disclosed both sexual assaults she had suffered. She was provided with information about the University’s Mental Health Advisory Service.
In a statement provided to the inquest, a member of reception staff at the Crown Hill halls of residence explained that around midday on 21 February, 2018, Ceara came to reception with a friend and reported that she had taken an overdose. A taxi was called which took Ceara to the Royal Liverpool Hospital. The staff member reported the incident to his supervisor who in turn contacted the hall warden, Dr Zeeshan Durrani. Neither the supervisor nor Dr Durrani reported the overdose to the University’s Student Welfare, Advice and Guidance (SWAG) team. During the inquest Dr Paula Harrison Woods, the head of student services at the University, said that she would have expected such a referral to be made.
After receiving treatment for the physical effects of the overdose, Ceara was seen by the Mental Health Liaison team at the Royal Liverpool. She explained that she was experiencing “psychological issues in regards to the sexual assault” and had self-harmed the previous evening as “she wanted to take her life”. The mental health nurse who saw Ceara concluded “there does not appear to be any indication that input from secondary mental health services is required at this stage” and told Ceara to see her GP and seek counselling. Neither the A&E department nor the Mental Health Liaison team wrote to Ceara’s GP to say that she had attended hospital following an overdose. The mental health nurse who saw Ceara told the inquest that she had forgotten to send the relevant paperwork to the GP.
On 22 February 2018 Ceara emailed a self-referral form to the University’s Mental Health Advisory Service, saying that she had started to work out the details of how to kill herself and intended to carry out the plan. When asked how many times she had done any of these things Ceara stated “Not sure. Around 10?” The form continued “my issues are interfering w/my everyday life & I feel they’re stopping me from reaching my full potential. They’re badly effecting my studies. I don’t know where to turn.”
A senior mental health advisor at the university, told the inquest that Ceara’s self-referral was not looked at for over a month, until 26 March 2018. She explained that this delay had been caused by a lack of staff, sickness and industrial action. When the advisor telephoned Ceara on 26 March she offered her an appointment on 5 April 2018, which was during the Easter holiday. Ceara responded within 26 minutes to request an alternative appointment as she would not be back in Liverpool until 6 April 2018. In a statement to the inquest the university mental health advisor explained “the next available appointment was then on the 24th April which I offered to Ceara and she accepted.” As a result Ceara was not seen by the University mental health service for over two months after her email asking for help.
On 24 March, 2018, Ceara again completed on online self-referral to Talk Liverpool, explaining: “I’m too depressed to function most of the time, but this is largely due to crippling paranoid intrusive and obsessive thoughts, often regarding suicide.” A Cognitive Behavioural Therapist from Talk Liverpool who carried out an Initial Telephone Assessment with Ceara on 10 April told the inquest that she assessed Ceara as suffering from “severe symptoms of depression” and “severe symptoms of anxiety” which were “impacting on all aspects of her functioning”. The therapist explained that Ceara was experiencing “daily thoughts” of “being better off dead or hurting yourself in some way” that she “reported that she self-harmed on an almost daily basis” and that her self-harming “had increased in frequency since coming to University in September.”
The following day the therapist faxed a referral to the Trust’s ‘Single Point of Access’ for specialist mental health services stating that during the assessment she was “concerned for” Ceara’s “safety”. The letter continued “Miss Thacker is aware that we are not able to offer a crisis intervention. Following discussion with Ceara and Talk Liverpool manager we agreed that Talk Liverpool is not suitable for Ceara's current needs due to her level of risk. I have therefore referred her to the Access Team a more thorough assessment”. A copy was sent to Ceara’s GP by post.
The referral was reviewed at the Single Point of Access by Advanced Nurse Practitioner, John Stephens, who decided to offer Ceara a routine appointment for over a month away, on 18 May, 2018. Nurse Stephens told the inquest that there was no system in place within the Single Point of Access at the time to guide staff as to how urgently referrals should be seen.
Ceara attended her GP on 13 April, 2018, for a physical health appointment. The GP noted that Ceara was “a little stressed recently” but they did not discuss Ceara’s mental health or antidepressant medication, which had run out several months before. In a statement to the inquest the GP, Dr Donna Evans, explained that the posted copy of the Talk Liverpool assessment didn’t arrive until after Ceara’s appointment. A ‘serious event audit’ carried by the surgery after Ceara’s death found that where there are “severe concerns we would expect a phone call from Talk Liverpool staff member or urgent fax which is dealt with on the day via duty doctor workflow tray” and that Ceara’s “case has highlighted that communication between various organisations in Liverpool could be improved.” After the letter was received the surgery left Ceara an answerphone message and sent her a letter asking her to get in touch with them. When asked at the inquest whether this was a sufficient follow-up, Dr Diane Exley, the ‘student lead’ for the Brownlow Hill Medical Centre admitted that is was “potentially not”.
At her only appointment with the University’s mental health service on 24 April Ceara explained that he was self-harming and had stopped taking her antidepressant medication. It was agreed that the advisor would contact Ceara’s GP and the University’s disability service, and would arrange for a further counselling appointment. The advisor stated in evidence that she did not ask about sharing information with Ceara’s family and intended to do this at the next meeting. However, none of this happened by the time of Ceara’s death.
At around 11.30pm on 11 May, 2018, a residential advisor at the Crown Hill halls of residence was asked to look in on Ceara after friends raised concern about messages she had sent and not being able to contact her. The advisor found Ceara hanged in her room. The inquest heard that despite being first aid trained the advisor didn’t cut Ceara down or attempt resuscitation but instead left the room, asked for an ambulance to be called and telephoned the hall warden. Dr Durrani, told the inquest that when he arrived at the scene a short time later he concluded that Ceara was beyond saving. Pathologist Dr Robinson told the court he was “unsure why Ceara was not cut down”. Responding to questions from the family’s barrister, Tom Stoate of Garden Court Chambers, Dr Robinson said that “it is possible” there could have been a different outcome had the first response from University staff been different. Ceara was declared dead by paramedics at the scene.
A Root Cause Analysis investigation carried out by the Trust concluded:
• There was a “Lack of understanding of the risks of suicide”
• There had been “No discussion between practitioners to fully understand risks.”
• There were “no established links of communication between mental health services and Liverpool university mental health services.”
• There was a “lack of joined up communication and established pathways between mental health services and mental health provision in the university for students.”
• “There is a tendency for clinicians to put the onus on the service user for follow up when sometimes assertive approaches are required for example requesting proactive G.P. follow up after A&E attendance.”