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Investigation and inquest
On 24th June 2021 I commenced an investigation into the death of Louise Asha Allen, aged 41 years old. The investigation concluded at the end of the inquest on the 5th July 2022. The conclusion of the inquest was a narrative conclusion:
Louise Allen took her own life whilst suffering from a mental health disorder. She was recognised as a very high risk to self, but in the months leading up to her death she did not receive the care that was necessary to protect her from the high risk which she presented.
Circumstances of the death
Louise Allen suffered from bipolar disorder and emotionally unstable personality disorder. She was discharged from hospital following a lengthy admission to hospital in mid-December 2020. She was regarded as a very high risk to self and she required a careful and comprehensive community care-plan. Between February 2021 to June 2021 she did not receive the necessary mental state assessments by her care-co-ordinator; there was no additional support provided to engage her in activities to assist in promoting her recovery. In addition, inaccurate clinical details were on occasion presented to the multi-disciplinary team, resulting in unreliable risk assessments. On the evening of the 12th June 2021 Louise travelled to ████████ where she placed herself in front of a train.
Coroner’s concerns
Louise Allen did not receive a care plan that was adequate to address the high-risk of harm to herself. This was largely due to failings in the co-ordination of her care. The Inquest heard that care co-ordinators are fundamental to the safe provision of care for high-risk service users. Concerns heard during the evidence at the inquest include:
1. There is a need within the Trust for better continuity of care. There are not enough care co-ordinators to ensure that continuity of care is provided. There are high turnovers of staff.
2. Efforts need to be made to make the post of care co-ordinator more attractive. The evidence heard that the pay within North East London Foundation Trust is not comparable to other Trusts.
3. Care Co-ordinators within the Trust are currently carrying excessive caseloads.
4. There has been an increase in the number of referrals coming into the service. There has been no commensurate increase in the number of care co-ordinators.
5. Whilst the Trust has over recruited in terms of the financial budgets, it is still under recruited in terms of the clinical need for care co-ordinators.
Information checked against the published report and official responses