Mental health team's 'missed chance' to save Telford woman
Mental health service workers missed an opportunity to help a woman before she committed suicide – though a coroner ruled it may not have prevented her death.
Carol Gillian Jackson, 60, was found dead at home by her husband a few weeks after being seen by mental health services.
At an inquest into her death, it was ruled that opportunities were missed that could have offered support to Mrs Jackson that may have offered her short term help.
Shropshire Coroner John Ellery said that the missed opportunity may have affected the outcome.
Mrs Jackson, who had a history of mental health problems, was found dead at her home in St Georges, Telford, on December 1.
In November, she had been seen by psychiatrists at hospital who had advised Shropshire and South Staffordshire Mental Health Trust crisis teams based in Shropshire to visit Mrs Jackson.
But an investigation from Kevin Mansell, from the trust, showed that there had been a discussion between the crisis team and the community mental health team about what extra advantage their visit may have provided.
Eventually, she was not visited and received only a phone call from the community mental health team.
Speaking at her inquest, held at Wellington Civic and Leisure Centre on Tuesday, Mr Mansell said he felt that the crisis team should have accepted the referral and arranged to visit Mrs Jackson straight away.
He said: "My belief is that is that the referral should have been accepted and a visit should have been made and if there was no need for their intervention that could have been decided at that point."
Mr Ellery recorded the cause of death as suicide but said an opportunity was missed that could have offered short-term help to Mrs Jackson, though it was not clear what affect that may have had on the outcome.
Following the investigation into her death, Mr Mansell said changes were now being made within the trust to make risk management more clear, to make the putting together of reports quicker and ways to speed up response to people in urgent need.
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