Health trust admits to failing Lizzie at inquest

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A health trust has vowed that changes will be made following the death of a “depressed” young woman who took her own life just days after being discharged from Weller Wing.

At an inquest into the death of Elizabeth, known as Lizzie, Barnes, her parents Nigel and Diane told the court they felt that their daughter had been “let down by the system” following a series of failings by the South Essex Partnership University Foundation Trust (SEPT) which oversees mental healthcare in the area.

They said they were not consulted enough during the time Lizzie was in the care of Weller Wing or given any advice or support after Lizzie was discharged.

20-year-old Lizzie, who was a student at Nottingham University, had been depressed for some time and made her first attempt on her own life in August.

Following this an appointment was made at the Mental Health Assessment Unit (MHAU) at Weller Wing, but after a meeting with a number of doctors and mental health staff she was told they could not offer her any help.

The court also heard that the team at the MHAU did not see any notes from Luton & Dunstable Hospital where Lizzie was treated after her first attempt, or suicide notes that Lizzie had left.

In a report compiled days after he death by her parents that was read out in court, they said: “We are certain if a mental health practitioner or doctor could have seen them it would have helped Lizzie get the help she so badly needed.”

But in evidence given by consultant psychiatrist Doctor Trilak Ratnayake, he claimed that seeing the suicide notes would not have changed his decision.

Lizzie returned home from university at the end of November where she made another attempt on her life. She was admitted to the MHAU on December 1 at Weller Wing this time, but was told she could be discharged several days later on the decision of one nurse.

The following day she made another failed attempt on her life and then tragically on December 6 killed herself.

After the inquest parents Diane and Nigel said: “When Elizabeth was in Weller Wing she was seen my mental health workers, but not one of them made the effort to discuss her mental health or treatment with us, her parents, despite several request, and Elizabeth’s consent to do so.

“There were key factors in her case that we never knew until after her tragic death.

“Lizzie took her own life after a catalogue of errors, lack of care and lack of communication from the very people we trusted as the trained professionals.

“She never saw any hope that she would get better, or get any worthwhile treatment. She should be here today enjoying her young life among family and friends.”

The inquest heard that SEPT admitted to failings in the care of Lizzie and produced an action plan with a list of six recommendations it plans to put into place over the next few months.

These include that “communication with carers needs significant improvement”, and a “nurse will no longer be able to discharge a patient without consulting with a psychiatrist first”,

Assistant coroner Belinda Cheney concluded that Elizabeth died of suicide following discharge from hospital on two consecutive days after previous suicide attempts.”

Her parents paid tribute to Lizzie after the hearing saying: “Elizabeth was a very kind, quiet, intelligent and beautiful fun-loving lady, who never had a bad word to say to anybody.

“We miss her so terribly that we find it difficult to put our loss into words. Lizzie loved her family, many friends, our dogs and her ponies and horses.

“She enjoyed the countryside, keeping fit, holidays and socialising. We will always treasure our memories of our last family holiday to Kenya.”

A spokesman for SEPT offered its sympathies to the Barnes family following the inquest.

They said: “The Trust has engaged with the family and shared the internal investigation into the incident where the learning was identified.

“The Trust has since implemented an action plan to ensure all of this learning has been fully addressed and continues to focus on

ensuring high quality services are provided within Mental Health Services in Bedfordshire.”