A jury spelt out significant concerns when it returned its conclusions about the death of a woman from Brighton who hanged herself last year.
Caroline Forte, 35, a self-employed graphic designer, was on leave from a hospital where she had been detained when she died at her home in Clifton Hill, Brighton, in February 2022.
The jury said that Caroline Victoria Forte died as a result of suicide while detained under section 2 of the Mental Health Act with a provisional diagnosis of severe depression with psychotic symptoms.
They said that a number of factors contributed to her death including inadequate communication within Amberley Ward, the psychiatric unit at Eastbourne District General Hospital. They said that there was also inadequate communication between the ward and Miss Forte’s family.
When Miss Forte went home on “section 17” leave, as part of preparations for her discharge, the jury found that there was no evidence of an “overnight care plan” or risk assessment.
The jury said that the staff on the ward, employed by Sussex Partnership NHS Foundation Trust, had failed to follow the trust’s “section 17 leave of absence policy”.
The coroner Penelope Schofield said that she would be writing three “prevention of future deaths” reports and a letter of concern.
One of the reports aimed at preventing future deaths and the letter of death would be sent to Sussex Partnership.
The coroner said: “There have been clear failings around record-keeping and a failure to keep to policies.”
She dismissed suggestions of a rogue member of staff – an unnamed ward clerk who had been replaced – and said: “It was clear … that this went far wider than one rogue member of staff.”
The coroner said that her letter of concern related to a serious incident review carried out by the trust which appeared to have resulted in no action plan or follow up.
Another prevention of future deaths report would go to the College of Psychiatrists because of concerns about information sharing between private psychiatrists and NHS trusts.
The final report – either to the Health Secretary or NHS England – would ask health chiefs to address the lack of advice for families.
With mental health services under greater pressure and families providing more care, “these families need the tools to support their loved ones.”
The coroner added that other deaths could be prevented if family members were helped to understand how they could reduce risks and look out for their those with mental health difficulties.
Miss Forte’s family attended all four days of the inquest. Afterwards the family said: “As heartbreaking as it has been to relive it all again, this inquest has been very important for us as a family to get some answers.
“Caroline was under section 2 of the Mental Health Act and as a family we trusted in the medical professionals and care system to keep her safe. They did not do that.
“There have been a number of admitted failings in the care that Caroline received. As her family we received no pertinent information or advice that enabled us to support her.
“This inquest has shown that the failings were not just at an individual level but were system-wide.
“We believe there needs to be accountability by Sussex Partnership Trust to take immediate action in order to prevent a repeat of the failures that occurred.
“We have lost a vibrant, talented, witty, loving and very much adored member of our family.
“Caroline is a daughter, sister, aunty and dear friend as well as an inspiring and award-winning creative partner to many well-known brands.
“We miss her every day and her 35 years are certainly not defined by this relatively short illness – and we will continue to treasure all of our memories of her.”
The inquest took place at Brighton and Hove Coroner’s Court, sitting at the Leonardo hotel, formerly the Jurys Inn, in Stroudley Road, by Brighton railway station.
Afterwards, Sussex Partnership NHS Foundation Trust said: “We offer our sincere condolences to the family of Caroline Forte.
“We apologise unreservedly for the failings in the care and support we provided Caroline and her family. We will respond to the issues identified by the coroner and Caroline’s family as a priority.”
NHS Mental Health & Social Care services have been in crisis for years, it is worse now than ever before.
Parents & carers can complain via PALS but nothing ever happens until Coroners reports are published years later when Trusts responses including Sussex Partnership NHS Trust are lessons must be learned, but they are never learned as the avoidable deaths continue. Trust Chief Executives certainly SPFT in my experience have little empathy nor understanding. Doctors working to Trust criteria seem able to discharge suicidal patients at a whim with little regard to warnings or previous history & without proper Risk Assessments. The system is broken requiring IMMEDIATE overhaul & Government intervention.
I blame the Government for failing to support NHS Mental Health Services.
DB..
Well said.