Elena WELLS · Prevention of Future Deaths report

On 30th March 2020, I commenced an investigation into the death of Elena WELLS aged 31 years. The investigation concluded at the end of the inquest on 9th November 2020. The conclusion of the inquest was a NARRATIVE CONCLUSION:-

Elena Wells who had a history of mental health issues died from the effects of placing a tight ligature around her neck in circumstances where she was alone in her home, waiting for the ambulance to take her to hospital for a necessary admission regarding her mental health. The ambulance was delayed and other health professionals were waiting for its arrival to be with her. She appears to have read a phone message at 14.15 on 19th March 2020 but had failed to answer a slightly earlier call from her lead practitioner which caused concern. At approximately the same time as she read the WhatsApp message steps were being taken to get into her property which took a further 20 minutes. She was found with the ligature around her neck in the bedroom. Emergency services were called and resuscitation was attempted by those at the scene but she was not able to be revived. On balance of probabilities, at the time she knew people were at the door she took the steps to tie the ligature and end her life.

The medical cause of death was:-
1a) Hanging
b) ---
c) ---
11. Bipolar affective disorder

Ms Wells returned to the UK in 2019. She had negative experiences with mental health treatment abroad which affected her trust of authorities on her return. In December 2019 when her mental health declined further she was referred to her local Mental Health Trust (the Trust). Seen twice in January it was agreed that she needed intervention from the Crisis Team. After 4 weeks she was transferred back to her Lead Practitioner (LP). In March the new Covid-19 restrictions negatively affected Miss Wells, and she became reluctant to take medication and was practising tying ligatures. Her LP recognised further decline. A Mental Health Act Assessment was quickly arranged on 18th March 2020 with two Doctors from the Trust and an Approved Mental Health Practitioner (AMP) from the Local Authority. An urgent informal admission rather than under Section was deemed necessary- she agreed. A local bed was not immediately available. She was deemed safe to remain at home until a bed was found on the basis that protective factors of (amongst others) her dog and flatmate were there. Advice included checking she had Crisis Team numbers and to attend A & E if necessary but there was nothing else in place to support her overnight to the following morning until a bed was found. The AMP was to find a bed however; one was not available until nearly lunch time the 19th March 2020. During the night she deteriorated. Her flatmate supported her and contacted the LP the following morning expressing concerns; she then had to leave for work. Miss Wells had one lengthy phone call with her LP but she was not visited by any health professionals, she was alone in the property after her flatmate had gone to a sitter. Her LP and the AMP communicated together but evidence suggested that there was confusion over who held overall responsibility for her care. The LP sought advice from senior practitioners who said she only needed to go to her when the ambulance arrived. The ambulance was delayed. Evidence showed Miss Wells read a WhatsApp message at 14.15 but had not answered the phone to her LP at 14.04. Concerns were raised and the AMP attended her property at approximately 14.30 but could not gain access. It was a further 20 minutes before access could be gained and she was discovered with a ligature around her neck attached to her bed. She could not be revived.

1. Both the Local Authority and the Trust were involved in the care of Miss Wells for the last 24 hours of her life. Evidence showed that there was a grey area in respect of responsibility for her care, at this time. There was no clear guidance as to who held overall responsibility for her care and there was no clear policy of how the two organisations should work together in these kinds of situations. It is requested that the Local Authority and the Trust consider how to improve communication and clearly define responsibility between the two organisations which could improve the safety of patients with serious mental health difficulties who were waiting for urgent admission to a mental health unit.

2. In this case a clinical decision was made to leave Miss Wells at home until a bed was found with Miss Wells, who was already ill enough to need urgent admission, having to inform the services if she declined further. No provision was made for Miss Wells to be reviewed out of hours, overnight and into the early morning by, for example, the Crisis Team, and no advice offered on the existence of a place of safety at the local Mental Health Hospital. Evidence showed that professionals can contact the Crisis Team in these circumstances but that is not done as a routine and patients appear to be left to make important decisions for themselves in circumstances where their declining mental health may prohibit them from doing so. It is requested that the Trust consider ways of providing extra support and supervision to those patients who are waiting for an urgent admission, particularly those who may be left alone at home for any period until a bed is found.