Failures at a mental health service have been found to have contributed to the suicide of a woman named Linda Banks, according to a coroner’s report. Linda had been in contact with the Tees, Esk and Wear Valleys NHS Trust for several weeks leading up to her death. However, the trust failed to view her as a genuine case and provided inappropriate advice to her family, suggesting they leave her alone. Linda’s loved ones feel that she was let down by the trust.
Linda Banks had a history of mental illness that worsened in February 2022 due to the death of her mother, financial stress, and attempts to quit drinking. Despite making multiple calls to the trust’s crisis team and being hospitalized twice for overdoses, her concerns were not taken seriously. Her family and GP expressed concerns about her deteriorating condition, but she was considered a low risk. Her care plan focused on bereavement counseling, help with alcoholism, and assistance with benefits.
The coroner, Janine Richards, identified a recurring theme in Linda’s care where her distress and paranoia were not given proper attention, leading to an underestimation of the risk she posed to herself. Linda’s family and friends were deeply concerned about her well-being, but her care was not escalated by the assessors. The coroner concluded that the trust’s actions and omissions had a significant impact on Linda’s death and that many of the systemic issues were already known to the trust.
Linda’s brother expressed the family’s disappointment and sense of betrayal by the trust. They witnessed her behavior deteriorate rapidly in the weeks leading up to her death, with severe paranoia and refusal to leave her house. Despite their concerns, they were told that she was not a danger to herself, and a mental health worker even suggested that they leave her alone. The family backed off, but Linda’s condition worsened further.
The trust disputes that anyone provided such advice, but the coroner was satisfied that similar advice was given, leading the family to back off. The coroner deemed this advice wholly inappropriate but in line with the clinicians’ beliefs about Linda’s condition. Linda’s family described her as a kind-hearted person who dedicated her time to raising money for mental health charities.
A serious incident review conducted by the trust identified several failures, all of which the trust accepted. These failures were the result of a thematic review conducted after the deaths of four patients. The review identified eight areas of failure, seven of which were still applicable at the time of Linda’s death.
The trust claimed to have made significant improvements and learned from these incidents. The crisis team, which had previously been in special measures due to staff shortages, was no longer in that situation. However, the coroner found the actions taken by the trust to be ineffective in preventing Linda’s death. She expressed concern about the timeliness of the changes and the length of time it was taking for reviews of serious incidents to be conducted. She intends to make a report on preventing future deaths regarding the issue of reviews.