Coroner slams west London mental health service after woman’s death

Image above: Westminster Coroner’s Court

A senior coroner has criticised the response of the West London Mental Health Trust after the death of a woman who was referred to them.

Valeria Munoz Biggs took her own life whilst suffering agitated depression, ‘possibly on the bipolar spectrum’. She died on 20 September 2019 after jumping in front of a train at Holland Park Underground Station. She was 31 years old at the time of her death.

Professor Dr Fiona J Wilcox, HM’s Senior Coroner for the area of Inner West London, said in her report to the Clinical Director of West London NHS Trust’s Acute Mental Health Services, that the team who were assigned to Valeria contributed to her death.

‘Her symptoms were not taken sufficiently seriously… If she had been adequately assessed and admitted to hospital, her death would not have occurred at this time’.

In her report, Dr Wilcox said:

‘On 12 September 2019, Valeria was actively suicidal and sought help on the advice of her psychiatrist of NHS services.

‘She attended A&E where she was found by Liaison Psychiatry to be mentally unwell and admission was discussed. She was concerned about admission and so was referred to the CRISIS Home Treatment Team, with a recommendation for low threshold for admission if her risk escalated or her family were not coping. She was directed to Care in the Community by the Home Treatment Team.

‘Overnight she was actively suicidal, attending a train station with thoughts of jumping before a train. This continued the next day. The Home Treatment Team did not visit on 13 September 2019 as planned and did not assess her suicidality or speak with the family, despite a contact from police that afternoon, informing them that a member of public had found her wandering expressing a wish to take her own life. I find this to be gross failure on the part of the Trust.’

Valeria’s suicidal thoughts continued and were ‘underestimated by the visiting team’ even though she had left her residence on 15 September with the intention of taking her own life on four occasions.

‘The family were unable to keep her safe. There were delays in psychiatric assessment, failure to increase her drugs adequately and persistent underestimation of her suicidality and failure to adequately engage with and listen to the family and note their concerns’.

Culture of ‘risk taking’

The coroner concluded there was a ‘team culture of positive risk taking’ that the NHS Trust needs to address. The team showed a repeated ‘lack of engagement’ with those who were attempting to look after Valeria at home and she was not properly offered admission to hospital, but rather ‘pushed toward care in the community’.

Had all of the necessary steps been taken, then Valeria’s death “would not have occurred at this time” Dr Wilcox reported.

The coroner also flagged up an inappropriate comment by one of the team which showed a lack of understanding of her illness.

‘Comments of a personal nature were made to her: paraphrased as “you are so pretty why would you want to kill yourself”, by a male member of the team in a clumsy attempt to cheer her up which she and her boyfriend who was present found offensive’.

There was a lack of proper assessment of suicidality, she said. For example: ‘seeming to ignore her actions, and concerns passed by her brother who was caring for her and over reliance upon no active suicidality being expressed when directly asked. Even when she was at times so unwell that she would not talk or was incoherent there was no reassessment of risk.’

At the end of her report Dr. Wilcox submitted eight primary concerns about the handling of Valeria’s case which she said should be addressed in order to prevent future deaths, claiming that this case “seriously calls into question the operational ethos of the care in the community approach in West London.”

She has given the Trust 56 days to respond.

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