- The inquest at Derby Coroner’s Court found that Valerie Weston died from immersion in water when her body was discovered in a Derbyshire canal
- Valerie Weston, who had been experiencing mental illness, had not been allocated a Community Psychiatric Nurse (CPN) for reasons which remain unclear
- The coroner found the lack of a CPN ‘undoubtedly affected’ the nature of the care for Valerie, who had reached out numerous times to mental health services
- Evidence was provided by witnesses including police officers, doctors and members of Valerie’s family
- Nelsons has been supporting the 61-year-old’s family
Derby Coroner’s Court concluded, by way of a short narrative, on Tuesday 5 September that the lack of a Community Psychiatric Nurse (CPN) ‘undoubtedly affected’ the nature of the care for a 61-year-old Derbyshire woman.
Valerie Weston, who died after immersing herself in a canal near Swarkestone Bridge in Derbyshire, had reached out for help multiple times in the days leading up to her death. The wife and mother of two was described by her family as loving and caring.
Valerie began experiencing mental health issues “virtually overnight” in 2017, after having no history of poor health, either mental or physical. Her symptoms worsened and escalated to an incident where she attempted to take her own life in December 2017. She was admitted to the Radbourne Unit at Royal Derby Hospital – part of the Derbyshire Healthcare Foundation Trust (DHFT) – where she received treatment and was discharged in January 2018.
Following discharge, Valerie continued to receive assistance from the local Community Mental Health Team (CMHT) – but Valerie’s family felt that this support was sporadic, with months between reviews and appointments.
From late 2018, Valerie’s mental health declined and again, the family felt that it was very difficult to obtain any timely help from the CMHT. The family were so concerned that they paid for Valerie to see a private psychiatrist. A CPN was requested to assist Valerie, but she was told by the CMHT that she did not fit the criteria.
In January 2020, Valerie had an inpatient stay in the Radbourne Unit following a further attempt to take her own life. Upon her discharge in February 2020, she quickly deteriorated.
Formal records from DHFT showed that Valerie was allocated a CPN during her admission. However, the CPN in question admitted in evidence that she had not been made aware of this allocation until the inquest. In summing up, the Coroner stated that he was “still rather confused and unsure” as to why the CPN was unaware. He held that in practical terms, Valerie did not have a CPN and that this undoubtedly affected the nature of the care which she received from Mental Health Services.
On 1 March 2020, Valerie was in contact with 111 on multiple occasions due to feelings of anxiety. She was able to speak to the mental health triage who made a referral to the CMHT. The following day, on 2 March, she attended her GP practice, Melbourne Medical Practice, where she was prescribed an increase in her medication.
On 4 March 2020, Valerie also attended A&E at Derby Royal Hospital as she was in an anxious state. An assessment was carried out, but it was determined that she had capacity and was free to go. The mental health liaison team at the hospital did not see Valerie in person while she was at A&E, stating that a face-to-face assessment was not needed. However, a Serious Incident report completed by the Trust following her death reported an in-person assessment would have been helpful. The Liaison Team member stated that if he had known she did not have a CPN, he would probably have assessed her face-to-face.
On 6 March, Valerie contacted the CMHT and informed them that she wished to end her life. Phone records indicate that no one got back in touch with her. Valerie then sadly took her own life later that day.
The cause of death was held to be 1a. immersion in water and 1b. anxiety and depression.
The inquest took place over two days from Monday 4 to Tuesday 5 September.
Valerie’s husband, Clive Weston, said:
“Valerie’s illness came on in a frighteningly sudden way, virtually overnight in the autumn of 2017. This was extremely difficult for both her and our family. While she received help at various times from different organisations, we felt that the support, particularly from the South and Dales Community Mental Health Team, was inadequate, with long gaps between appointments and a lack of consistency. We found that without regular support it was very difficult to manage Valerie’s health and medication.
“I worry about other patients, who don’t have the support of family and friends. I wouldn’t want anyone to go through what Valerie and my family have experienced, so I hope the services learn from the findings today and make the necessary changes to ensure calls for help are listened to and people get the care they need.
“Valerie was the most loving, caring and capable person and we miss her dearly. Valerie wanted to get better and did everything recommended, but she needed more support, which she repeatedly tried to access, even on the day she died. Valerie was selfless, kind and loving. A wonderful wife, mother, sister, auntie and grandmother who always put others first.”
“The inquest highlighted concerns about Valerie’s care and in particular the failure to provide a consistent point of contact for her. It is evident that she was experiencing serious mental health issues, but that the family struggled to access assistance.
“Today’s ruling comes after what has been an extremely difficult process for Valerie’s family. Three years on from losing a much-loved wife and mother, I am glad the family now has some answers, but the hope is that real lessons are learned here to avoid anyone experiencing the same pain.”