Vulnerable woman dies from hypothermia in Exeter council house unable to heat her home

A vulnerable woman died alone from hypothermia inside her Exeter council house because she could not heat it.

Cass Terry suffered from poor mental health for the majority of her life.

The 55-year-old had suffered through periods of self-neglect due to being diagnosed with a persistent delusional disorder.

An inquest at Exeter's Coroner Court today (1 March) heard the musician and artist had been under the care of Devon's Community Mental Health Team (CMHT) until November 2020.

The fire brigade was asked to break into her property in Redlands Close on 11 November 2021, after a neighbour reported not seeing her for a week and then seeing her lying on the floor when he peered through her letterbox.

The inquest heard Miss Terry's home did not have a fridge/freezer, washing machine or microwave, and she had not known how to use the heating system.

Her sister, Anne-Marie Rogers, questioned in a statement whether more could have been done to support her and whether a lack of care contributed to her living in poor conditions.

She said: "I have concerns about her death and the care she received or did not receive leading up to her death which I feel possibly contributed to her death."

She told how Miss Terry, an alcoholic, drank heavily to self-medicate.

A post-mortem examination confirmed the cause of her death was hypothermia and that she had not been intoxicated at the time of her death.

Regarding her lack of heating, Miss Rogers: "I have never known her to use heating, despite living in the flat for several years."

Describing her past struggles, she said: "She was put into care at age of 14 by Devon County Council and was also repeatedly sectioned in recent years.

"She had been homeless, once living in a cave."

She added: "She was suspicious of services given how she had been detained in the past."

An insight into her mental health in the weeks leading up to her death was provided by a neighbour who lived opposite Miss Terry and had also become a good friend.

He explained they were both alcoholics and would drink together, but that he no longer wanted her in his flat when her drinking increased and he would instead visit her flat.

In a statement, he said: "She started drinking more heavily in the months before passed away, about 10 cans of lager a day."

Recalling the conditions she lived in when she passed away, the neighbour said: "The weather was quite cold at the time and I know she always used to have her windows open.

"When I visited her flat previously I remember it being very cold and I said to put the heating on, but she said she did not know how to. I said she should contact ECC.

"In my opinion, she could not look after herself due to her drinking and she should have had a carer."

Devon Partnership Trust (DPT) mental health nurse Jennifer Kent told the inquest how Miss Terry came under the care of the CMHT in July 2019 following a hospital admission and presented with symptoms of psychosis.

"She was struggling in her flat and was feeling quite isolated. She was keen to engage in therapy," she recalled.

Miss Terry was appointed a support worker who would go to her home once a fortnight and was said to have tried to help her buy a second-hand fridge/ freezer - but she declined saying she was awaiting a new kitchen to be fitted and did not see it as an "urgent need" as she coped well without one.

No concerns were noted about the lack of heating and it was reported Miss Terry had the capacity to log any problems she was having with it.

The inquest heard she was offered a social care package by the CMHT, but she declined because she felt she was being well supported by her neighbour.

Ms Kent said: "We had to respect her choice and decision and she had the ability to weigh up her options.

"We felt she had insight and an ability to self-rescue by calling into services so that was quite a protective factor."

In October 2020, Miss Terry discharged herself from the service reporting that she was feeling "very stable" and that she recognised the importance of taking her medication to remain well.

The inquest heard how if the service had deeper concerns she would have been referred to its crisis team.

She was also not under the care of local addiction services stating she did not feel ready to give up alcohol.

During the discharge process, Ms Kent recalled that she had found out from the pharmacy that Miss Terry has not been collecting her medication and that the information was passed on to her GP who was then responsible for her care.

Her GP at Mount Pleasant Health Centre told the inquest that the surgery had received a discharge summary from the CMHT which suggested she was being supported by a partner, rather than a friend.

The GP added that had the surgery known this, they would have monitored her more closely.

No concerns were noted when she received an annual health check over the phone in February 2021.

Recording a conclusion of natural causes, area coroner Alison Longhorn said to her family: "It must have been very difficult to lose Cass in these circumstances and very difficult for you to accept she was very against getting help from anywhere and the help she needed she did not get."

Coroners have powers under Regulation 28 to make a report to prevent future other deaths.

However, Mrs Longhorn said it would not be appropriate in this case because the correct processes were followed by DPT services.

She said: "I do note that her death was over a year from discharge from the CMHT so it was clearly a significant time when she may not have been well but she was certainly not presenting to those around her that she was significantly unwell.

"There were no concerns when a GP spoke to her in February 2021."

Paying tribute to Miss Terry after the inquest, her sister Miss Rogers said: "Cass Terry, born Mary Rogers, went to school in Exeter at St Nicholas and St James.

"She was an artist and musician who sang with a band called Boomshack in Exeter in the 1990s. She was a gentle soul who loved animals.

"Her sensitive nature was badly affected when her father died 10 years ago.

"She then struggled with serious mental health conditions and drink problems.

"Despite being well known to Exeter mental health services, having been sectioned six times in four years including several occasions in Exeter, she was discharged during a lockdown and judged a ‘low risk’.

"Yet the mental health services knew she couldn’t cook for herself, didn’t have a fridge, wasn’t taking her medication, and had been sectioned the year before.

"She was discharged to her GP who didn’t see her once and wasn’t aware she had a drink problem. Cass didn’t know how to use her heating.

"She died cold and undernourished on the floor of her council flat, alone, apart from her pet dog Stanley.

"Cass’s death is an indictment of current mental health provision. The principle of self-determination seems to be used as an excuse to ration mental health services.

"Once discharged, there was no care for Cass. The mental health system that is set up to protect people like Cass has seriously failed her and our family.

"The family would like to thank Cass’s neighbour who offered Cass friendship and cared so well for her dog Stanley."

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