Mena Tekloe Marim Teferi · Prevention of Future Deaths report

On 10 October 2021 I commenced an investigation into the death of Mena Tekloe Marim Teferi, aged 49. The investigation concluded on 19 May 2022. The conclusion of the inquest was death due to suicide, the medical cause of death being
1a Suspension

Mena took her own life using a ligature and was found deceased at home, ████████ on 10 October 2021. She was under the care of the North Ealing Mental ████████ Health integrated network team but this team was critically under-resourced and unable to cope with the level of referrals to their service. She was not seen when she should have been on referral from the emergency department on 23 September, was not discussed in the daily zoning meeting as she should have been and was then lost to follow up the following week and not seen or contacted before her death. It is not possible to say if this could have changed the outcome.

The mental health services went through a transformation process during the Covid pandemic. It became apparent that the anticipated level of direct referrals to the service from primary care was many times in excess of those predicted. The expectation was 6 per day, at the peak this rose to 30 and has currently reduced to 13-14 daily, so remains over 100% above the anticipated level.

The inquest was advised that the service was failing to meet the service demands due to insufficient capacity. The decision was made to enter this onto the Trust’s risk register, and this remains the situation. The critical features remain a high demand for services and a lack of resources.

This court has been told on many occasions that there is an intention for “parity” of mental health services with physical health services, but this is not apparent and the service is unable to meet its obligations now or going forward. This is greater than a “long waiting list” issue and is not a situation that can be explained exclusively by the covid pandemic. A more significant risk to individuals requiring mental health services has now arisen than existed before the transformation programme; it creates a real concern that lives will be lost as a consequence, and no solution was offered to the court during the inquest. The service is set up to deal with less than half of the referrals that it receives, leading to inevitable failings that currently cannot be rectified.