Nottinghamshire woman, 22, was 'badly let down' by mental health services before taking her own life
An inquest found poor co-ordination between the agencies responsible for Beth's care contributed to her taking her own life, ITV News Central's Lee Comley reports
A 22-year-old woman who took her own life was "badly let down" by mental health services and professionals, an inquest has found.
Beth Langton, from Nottinghamshire, was found unresponsive in February 2023 while at accommodation designed to help women with Emotionally Unstable Personality Disorder.
The inquest at Nottinghamshire Coroner’s Court found that Beth died by suicide on 18 February 2023 at Oakwell House, in Retford, from the effects of a poisonous chemical.
She had received ongoing care and treatment for her mental health from a young age, including a number of periods where she was detained under the Mental Health Act.
Her family believe Beth would still be alive if there had been been better communication between the services in charge of her care.
What care did Beth receive before her death?
Beth had lived in Oakwell House, a supported living placement which specialised in caring for young women with Emotionally Unstable Personality Disorder (EUPD), since July 2021.
While living there, Beth also received input from a number of other bodies and agencies, including Nottinghamshire Healthcare NHS Trust, Nottinghamshire County Council, and other support services.
She initially received 24-hour-a-day one-to-one care from support workers at Oakwell House and struggled with frequent instances of self-harm.
Throughout her time at Oakwell House, Beth received input from a clinical psychologist, Gillian Merrill, who was contracted by the facility.
However, at an inquest into her death, the coroner heard evidence that Oakwell and Ms Merrill did not have any kind of written contract or terms of reference which set out what her role was or what she would provide to Beth.
Ms Merrill told the inquest that she did not prepare any formalised risk assessments or care plans, did not keep any clinical records of her work with Beth, and did not keep any records of her receiving clinical supervision for her work with Beth.
The coroner found that the fluid nature of this agreement and service created significant misunderstandings across the agencies involved in Beth’s care.
In April/May 2022, Beth’s family raised their severe concern about the decision by Nottinghamshire NHS Trust’s mental health team to discharge her for the first time in over a decade.
The coroner heard evidence the decision was taken in large part as a result of a mistaken understanding about Ms Merrill’s role and the psychological services she provided to Beth.
Beth is documented as having herself informed the mental health team at the time that she was not receiving the support they understood she would be, something which her care coordinator admitted at the inquest should have led to a reconsideration of her discharge.
The coroner also found that the discharge decision was not carefully considered, planned or structured, and was instead dropped on Beth and other professionals – there should have been a period of observation and support with a view to only discharging Beth if she remained stable.
The coroner found that Beth was likely to feel abandoned or rejected by this decision.
Through the spring and summer of 2022, Beth attended trauma therapy counselling sessions with a local charity.
However, in August Beth stopped these sessions and explained this was because Ms Merrill had offered to provide trauma therapy at Oakwell House instead.
Despite this and contemporaneous records from Oakwell noting a plan for trauma therapy to be delivered by Ms Merrill, none ever took place.
In December 2022 Beth wrote a note which recorded she felt tricked by Ms Merrill and Oakwell’s manager to stop trauma therapy.
At the inquest, Ms Merrill denied that she had ever offered to provide trauma therapy to Beth, however the coroner found that it was “abundantly clear” from contemporaneous records that Beth had been offered some form of new therapy for Ms Merrill to conduct, which did not take place.
From summer 2022 onwards, the mental health team continued to make decisions based on a misunderstanding of what psychological services were provided by Ms Merrill at Oakwell House, which included in December 2023 when the mental health team indicated they would not accept Beth back into their caseload because of the support they understood to be offered by Oakwell.
This indication was offered without speaking to Beth about the support she was receiving. Beth’s family believe that the decision not to accept Beth back on to the mental health team’s case load was a significant factor in her deteriorating mental health.
In January 2023 all one-to-one care at Oakwell was removed at Beth’s request, with Beth then remaining subject to ‘background’ staffing only.
This reduction in support was agreed by Beth’s social worker. The coroner found that this decision was made in isolation, without an understanding of what services were being offered to Beth at the time.
The coroner heard evidence that Oakwell's support staff had concerns that this decision was made too quickly and that Beth was not ready for the reduction in support.
In early February 2024, Beth decided to stop taking her prescribed anti depressants.
The inquest heard how Oakwell staff, despite being aware of the potential for side effects with the sudden cessation of medication, failed to follow their own policy and report this development to Beth’s GP.
Following Beth’s death, examination of her mobile phone by police revealed evidence of searches for suicide and self-harm methods.
What did the inquest find?
Area Coroner Laurinda Bower found that poor inter-agency working between Nottinghamshire County Council, Nottingham Healthcare NHS Trust, accommodation provider Creative Care and Beth’s clinical psychologist at Oakwell House led to misunderstandings and a disjointed package of care.
This led to Beth feeling that she was a burden to those supporting her, and that they did not wish to help her, which contributed to her decision to take her own life on 18 February 2023.
Recording death by suicide, the coroner found that those involved in caring for Beth were aware she had a personality disorder and should have known she would be particularly sensitive to feelings of rejection and abandonment because of these failings.
"She got tired of fighting"
Beth's mum, Shelley MacPherson described her daughter as a "very intelligent, very clever and witty" person.
She told ITV News Central: "Two police officers in uniform arrived at the door - that's how I found out. That was it. They didn't know any more details and obviously I had questions, you know...how...when...but they didn't know any of that.
"Particularly in the last year of her life, she just felt more that every way she turned that she was hitting a brick wall. I think she just got tired of trying to fight against the system, really. And just gave up."
Beth's mum Shelley remembers happy times with her daughter.
In a statement, Dr Susan Elcock from Nottinghamshire Healthcare NHS Foundation Trust said: “On behalf of the Trust I once again offer our deepest sympathies to Beth’s family and friends for their loss.
"We are working with our partner agencies to address the issues raised by the coroner and improve the experience of care for our current and future patients."
Creative Care Ltd, who own Oakwell House, said: "Creative Care remain deeply saddened by the death of Bethany Langton, who we knew by her preferred name, Beth.
"Creative Care is a residential home which provides support to women with mental health conditions, with the aim of providing a pathway to transition back into the community. It is important to note that it is not a hospital nor a mental health unit. One of the key functions is to support those using the service (“Service Users”) with their health needs and enable them to access their GP and/or the Local Mental Health Team.
"The decision as to the level of support received by Service Users in the form of a care package is determined by medical professionals and social services and not Creative Care.
"Whilst Creative Care did engage a self-employed clinical psychologist to provide a drop-in service for staff and residents this was not intended to replace any prescribed care package.
"A full and detailed investigation into the circumstances by which Beth sadly lost her life has been undertaken by HM Coroner for Nottingham. We fully assisted the Coroner with the investigation and provided clear and transparent evidence as to the role that we undertook. We are aware of the Coroner’s concerns around a misunderstanding about services that led to a disjointed package of care and steps have been taken to improve interagency communications. In particular regular visits from Community Psychiatric Nurses are now in place to enable discussions with staff and for any concerns to be addressed.
"The safety and wellbeing of our Service Users remains paramount. Beth’s death was a shock to all who knew her and we wish to offer our continued sincere condolences to the family and friends of Beth."
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Support and advice:
CALM, the Campaign Against Living Miserably, runs a free and confidential helpline and webchat. It also supports those bereaved by suicide, through the Support After Suicide Partnership (SASP). Call 0800 585858 (daily, 5pm to midnight).
Mind is a mental health charity which promotes the views and needs of people with mental health issues. It provides advice and support to empower anyone experiencing a mental health problem, and campaigns to improve services, raise awareness and promote understanding. Call 0300 123 3393 or email info@mind.org.uk
PAPYRUS aims to reduce the number of young people who take their own lives by breaking down the stigma around suicide and equipping people with the skills to recognise and respond to suicidal behaviour. It provides practical, confidential suicide prevention help and advice over telephone, text and email service which is staffed by trained professionals. Call 0800 068 4141, text 07860 039967 or email pat@papyrus-uk.org.
Samaritans is an organisation offering confidential support for people experiencing feelings of distress or despair. Phone 116 123 (a free 24 hour helpline) or email jo@samaritans.org
YoungMinds is a resource with information on child and adolescent mental health, but also offers services for parents and professionals. It is the UK’s leading charity fighting for children and young people's mental health, and wants to make sure all young people can get the mental health support they need when they need it. Visit youngminds.org.uk
Shout is a 24/7 text service, free on all major mobile networks, for anyone struggling to cope and in need of immediate help. Text SHOUT to 85258.
SOS Silence of Suicide provides a listening service for children and adults who need emotional support, understanding, compassion & kindness. Phone 0300 102 0505