A jury inquest into the death of a 24-year-old woman from Kent has today concluded that she died from suicide which was contributed to by neglect on behalf of Kent and Medway NHS and Social Care Partnership Trust, whose care Callie was under in the run up to her death.
The jury also found that there was a combination of individual and organisational failures amounting to gross failure in relation to Callie’s care, who was in a dependant position because of her depression and autism. They went onto list a number of failures in relation to individuals who failed to follow relevant protocols for dealing with Callie in the run up to her death.
Other failures which the jury say probably contributed to her death include a lack of training and knowledge in relation to autism and suicide forums, a lack of clarity and consistency regarding recording risk assessments and a failure to report relevant information. This may have been down to high caseloads.
Callie Lewis was found dead in Cumbria in August 2018. She had been missing for more than a week and died as a result of carbon monoxide poisoning.
During the 10-day inquest, Senior Coroner Patricia Harding, heard evidence from Sarah Lewis, Callie’s mother. She also heard evidence from Kent and Medway NHS and Social Care Partnership Trust, whose care Callie was under in the run-up to her death, and Kent Police, who had contact with Callie prior to her death.
Speaking after the inquest, Sarah Lewis said: “Callie was a spirited, determined and exceptionally intelligent young woman, who left an impression on everyone who met her. She was a much-loved daughter, sister, granddaughter and niece.
“When Callie became very ill during the summer of 2018 we, Callie’s family, desperately sought to ensure she was somewhere she would be safe and could receive the treatment and care she needed.
“We are very grateful to those who listened to us and who took our concerns seriously, including the police officers who sought to keep Callie safe. We will always remember their professionalism and compassion.
“Unfortunately, Callie was badly let down by not receiving the treatment, care and intervention she needed to keep her safe at this critical time.
“I told every professional I spoke to at the time that Callie would die within the next few days if she did not receive the support she needed. I also told them exactly how she would die. I wish I had been believed.
“We, Callie’s family, did not know that Callie had been released into the community. She did not receive any care at all after her release and we have heard over the past two weeks of a staggering catalogue of failures which contributed to her death by the NHS Trust that was supposed to keep our daughter safe. By the time the people responsible for her care realised they had lost her, it was already too late.
“I would like to express our thanks to the jury, coroner and all parties for their constructive and thoughtful handling of the past two weeks.
“I would also like to thank the charity INQUEST for their support and our lawyers, Nancy Collins and Mickey Keller at Hodge Jones & Allen who have been with us every step of the way through this process.
“We sincerely hope that lessons are learnt so that other families do not have to go through what we have had to go through.”
Nancy Collins and Mickey Keller are civil liberties solicitors at London solicitors’ Hodge Jones & Allen representing Sarah Lewis. Nancy Collins says: “Callie’s family speak of her intelligence and spiritedness and her importance to them. She was a young woman who was struggling with depression and with her autism, who was terribly let down by the lack of care and support available when she was in crisis and unable to manage her thoughts of suicide.”
Deborah Coles, Director of the charity INQUEST, said: “Callie was a young woman with autism who was in a mental health crisis and needed urgent support. The systems built to respond to this had the chance to protect her. Her family fought for them to do so. Yet they failed Callie and her family, missing multiple opportunities to intervene.
“Too often families with a lifetime of knowledge on the needs of those with autism or mental ill-health are ignored. Instead, mental health and public services rely on rushed assessments and little to no knowledge on such vulnerabilities. This failure in communication continues to have devastating consequences, and must be addressed at a national level.”
Counsel was Victoria Butler Cole QC of 39 Essex Chambers.