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Inquest Concludes NHS Trust Failures Contributed To Woman’s Suicide

Michelle O’Neill, described as a kind and caring person who was “strongly motivated to help others”, was left believing that professional help would never be available for her after being “passed from pillar to post” by Oxleas NHS Trust

At an inquest held at East Sussex Coroner’s Court, HM Assistant Coroner Michael Spencer concluded that failures by Oxleas NHS Trust to provide Michelle O’Neill with adequate mental healthcare coordination and therapeutic support contributed to her death. Michelle, a 54-year-old domestic abuse support worker from Eltham, South East London, died by suicide on 28 February 2020.

The Coroner found that Michelle was “passed from pillar to post” within the Trust, “without anyone taking responsibility for her care in the medium to long term, which resulted in her slipping through the cracks”. He found that there was no care coordinator nor any long-term care planning for Michelle. He further remarked that there was inadequate assessment and understanding of Michelle’s risk to herself, with overreliance on the “here and now” and insufficient consideration of external and maintaining factors in her depression and risk.

Michelle experienced her first mental health crisis in March 2019, almost a year before her death. The inquest heard that over the following year, circumstances in her life – including allegations of domestic abuse against a former partner, the financial stress arising from that abuse as well as an ongoing investigation against her by the Metropolitan police – had a severe and adverse impact on Michelle’s mental health. The Coroner found that the Trust failed to implement any long-term plan for her care to support her through these life events or provide appropriate therapeutic intervention, and that this contributed to her death.

By May 2019 Michelle’s mental health had deteriorated so significantly that she was admitted to the Millbrook Ward at Queen Mary’s Hospital as a voluntary inpatient. She was discharged on 14 June 2019. The inquest heard evidence from Michelle’s sister Deborah that following her discharge from the ward her family had to keep her under constant watch, but that they were unable to keep her safe. Over the next four months, Michelle made several attempts to end her life, by either travelling to the coast or taking overdoses. Her suicidal behaviour began to escalate and in August 2019, after Michelle’s family called the Oxleas crisis line in another desperate attempt for help, Michelle took a massive overdose of paracetamol and alcohol. As a result of this she was hospitalised for a month.

During the same period, Michelle was meant to receive support from the ADAPT team, a community service designed to provide long-term therapy for patients with mental health conditions. However, despite the increasingly serious attempts on her life from 14 June 2019 until her death in February 2020, Michelle was discharged from the ADAPT team three times without ever receiving an assessment or therapy. Michelle was also repeatedly discharged from other community services, including the Home Treatment Team (a crisis service) and a counselling service called Greenwich Time To Talk, without ever receiving counselling nor being seen by a psychologist or a doctor.

In January 2020, Michelle was re-referred to the Primary Care Plus Team by her GP, who felt that her current medications were not enough to control her symptoms. During telephone conversations with the Primary Care Plus Team Michelle was noted to be “very very manic”. The inquest heard expert evidence that at this point Michelle should have been provided with an urgent appointment and assessment, and indeed Michelle herself requested that her next appointment be brought forward. Instead, the Trust pushed her appointment back by a month. The Coroner identified this as a further failing by the Trust and “a missed opportunity to assess, identify and take steps to mitigate Michelle’s risk to herself.”

On 16 February 2020, Michelle went missing; she travelled to Hove and made an attempt at suicide in the sea. The Metropolitan Police notified Oxleas of the incident and Michelle was considered by healthcare professionals to be “high risk pending further assessment”. A nurse determined to “make urgent contact” with Michelle, and left voicemails for Michelle and her family members. Michelle returned the nurse’s call 15 minutes later and was put through to her voicemail. However, the nurse did not retrieve the voicemail nor make any further attempts to contact Michelle. She told the inquest that she assumed that Michelle was safe because she was with her family. The Coroner identified the failure to urgently assess Michelle at this point, or put in place any measures to mitigate the risk to herself, as a further missed opportunity on the part of the Trust to provide effective healthcare to Michelle.

On 28 February 2020 Michelle went missing for the final time. Her family called the police and told them that she was likely to head for the coast to end her life. That evening, a woman was sighted acting strangely on some rocks on the beachfront in Hastings during Storm Jorge. A search by Sussex Police did not manage to locate the woman and it was called off later that evening. Michelle’s body was found the next morning on Camber Beach. The Coroner concluded that it was likely that the woman seen on the rocks was Michelle and that she had entered the water in Hastings.

In his final ruling, the Coroner remarked that “it is difficult to describe the service she received from the Oxleas Trust in the year preceding her death as anything other than disjointed and reactive” and that in his view “proper long-term care coordination, with appropriate therapeutic intervention, would have made a difference to the outcome for Michelle”.

Hayley Chapman and Alice Hardy of Hodge Jones & Allen acted for Ms O’Neill’s family. The family were represented at the inquest by Kirsten Sjøvoll of Matrix Chambers.

Michelle’s son Connar Higgins, her twin sister Janet O’Neill and her elder sister Deborah O’Neill, said:

“Michelle had helped so many others throughout her life, but when she asked for help herself she was consistently denied any meaningful assistance, which added to her suffering. It has taken far too long to reach this point but we are rightfully glad that the Assistant Coroner has made critical findings against Oxleas NHS Trust. We urge anyone in a similar situation to seek legal advice and fight for justice. Thank you to our legal representatives for their help in obtaining justice for Michelle O’Neill, a wonderful mother, daughter, sister and friend.”

Hayley Chapman, Solicitor at Hodge Jones & Allen, said:

“It is dismaying to see how a woman in Michelle’s position kept asking for help, but was repeatedly discharged without receiving any therapy, care coordination or proper recognition of the risk she posed to herself. It is right that the Coroner has recognised the seriousness of the Trust’s failures in Michelle’s case. Michelle’s family have fought for three years to get to this point, and we hope that during this time lessons have been learned so that no other family has to suffer like they have.”

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