Dead woman's care team is told: you just let her down

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Saturday, March 14, 2009
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This is Derbyshire

MENTAL health staff have been criticised for failing to visit a depressed pensioner who later died after cutting herself.

Margaret Hallsworth, of Heanor, suffered from emotionally unstable personality disorder, a condition which left her feeling depressed and sometimes even suicidal, an inquest into her death heard.

The 66-year-old had threatened to commit suicide in the past, although her family and health officials considered this more of a cry for help than a serious attempt to end her life.

She was found dead at her home in Roper Avenue on the morning of July 27 last year.

A pathologist found that the cause of death was loss of blood due to a number of self-inflicted cuts on her body. Most were superficial but one wound had extensively damaged a large vein.

Two days earlier, she had been admitted to Derbyshire Royal Infirmary after taking an accidental overdose of anti-depressant drug temazepam in an attempt to get some sleep.

She was allowed home that night and, the following morning, a member of Derbyshire Mental Health Services Trust's crisis team phoned to check her condition and spoke to her.

They phoned again that night but Mrs Hallsworth did not answer.

Derby and South Derbyshire Coroner's Court heard from community mental health nurse Natasha Bain that, in such cases, the procedure should have been to try Mrs Hallsworth's mobile number and, if there was no still no answer, make a home visit.

But no further contact was made until the following day, when a team member called at the house, by which time Mrs Hallsworth was dead.

Mrs Hallsworth's daughter, Tracey Bates, and ex-husband Alfred Bates told the hearing they did not understand why the team had not tried harder to make contact.

Mr Bates, who spent most of the day before her death with his former wife, asked: "Why didn't someone go if they got no response? It would have saved a lot of distress if they had. You just let her down."

Ms Bain told the court that she and members of the crisis team had been in regular contact with Mrs Hallsworth in the days leading up to her death.

She said the pensioner had been distressed and anxious and that staff had advised her over the phone and on home visit about coping strategies.

When asked by deputy coroner Catherine Mason why further efforts to contact Mrs Hallsworth had not been made, Ms Bain said: "It could have been done better."

In recording a narrative verdict, Ms Mason said: "It is not clear from the evidence wether she intended to take her own life. At the time of her death, Margaret Hallsworth was under the care of the crisis team.

"Policies were in place which should have been followed but they were not. However, it's unclear whether the outcome would have differed were policies followed."

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