NHS mental health trust failings contributed to Ferryhill woman's suicide, coroner finds

Failures by an NHS mental health trust contributed to a woman taking her own life, a coroner has said.

Linda Banks, from Ferryhill, died in April 2022 after receiving treatment from the Durham and Darlington Crisis Team, run by the Tees Esk and Wear Valleys NHS Foundation Trust.

The 48-year-old had learning difficulties and a long history of mental illness, but had "extensive contact" with the trust in the months before her death.

At an inquest at Crooks Coroner's Court on Monday 18 December, a coroner found that the trust had underestimated her risk while advice given to her family and friends to show her "tough love" was "wholly inappropriate. She also commissioned a future deaths report, in a bid to stop those failings being repeated.

The trust has apologised to Ms Banks' family and vowed to act upon the inquest's findings.

Ms Banks spent much of her life raising money for mental health charities but had been badly struggling with her own mental health in the months before her death. The inquest heard she had been grieving for her mother and was struggling with alcohol dependency.

She had contacted the Durham and Darlington crisis team, a service for mental health emergencies, on several occasions but her case was not escalated as it should have been.

The inquest heard that the Tees Esk and Wear Valleys NHS Foundation Trust was under special measures at the time, suffering staff shortages while unqualified staff were also carrying out assessments.

Ms Banks was twice admitted to hospital after harming herself but she continued to be classified as low risk.

A friend of Ms Banks had gone to the trust for advice on how to help but was told to show her "tough love" instead. The claim was disputed by the trust during the inquest but the coroner said she was satisfied family and friends were given advice to step back and described the advice as "wholly inappropriate."

Speaking on behalf of the family after the inquest solicitor Lois Hepworth said: "We are pleased that the coroner has found that Linda's death was contributed by the failures of the trust. We feel if we were listened to by the trust Linda would still be with us today.

"We hope by speaking out we can raise awareness and ensure that the promised changes are made so no families have to go through what we went through and no more are bereaved."

Following Ms Banks' death, the trust's own investigation found that there was a lack of awareness in team processes meaning she didn't receive the right care and her needs were not fully met. It also highlighted that there was problems with the trust's triage tool and assessments were not done properly while communication was also an issue.

Tees Esk and Wear Valleys NHS Foundation Trust have pledged to act on the inquests' findings and to make improvements.

Beverley Murphy, chief nurse at the trust, said: “Coroner hearings can be very difficult for a family, and Linda’s family have been in our thoughts throughout. We are truly sorry for their loss.

“We reviewed Linda’s care and listened closely to the concerns of her family. We identified areas to improve and have been working hard to make these changes.

“We will act on the inquest findings and remain committed to these improvements and providing the best care possible.”

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