Barbara Mary Anne Mayer · Prevention of Future Deaths report

On 17 November 2014 I commenced an investigation into the death of Barbara Mary Anne Mayer Aged 72 years. The investigation concluded at the end of the inquest on 11 March 2015. The conclusion of the inquest was medical cause of death: drowning; and conclusion: “Suicide whilst under the care of Mental Health Services”.

Mrs Mayer had a long history of depression. Her anxiety increased in 2013 when she suffered a number of physical health problems. She was reviewed regularly by her GP who referred her for a mental health assessment in September 2014. Her care was passed to the Dementia and Complexity in Later Life Team. She continued to ask her husband to help her end her life. She was discharged by the Crisis Team to the Community Mental Health Team on 15 October 2014. Her GP referred her back to the Crisis Team for assessment on 12 November 2014. On 14 November 2014, Mrs Mayer begged her husband to help draw her in the bath. ████████ called the Crisis Team who were unable to attend due to levels of work elsewhere. Her Care Co-Ordinator did attend to see her. ████████ was contacted by the Crisis Team to say someone would be visiting that day. At 21:15 hours a telephone call was made to say someone would attend after midnight for an assessment. As Mrs Mayer had taken sleeping medication and was getting ready for bed, it was agreed someone would call to see her the next morning. At some time between 02:00am and 05:00am Mrs Mayer left the house, leaving a pillow in her bed in place of her body. She was found on 16 November 2014 drowned in a nearby pond.

(1) Mr ████████ was noted to show signs of Carer fatigue, but this was not followed up;
(2) Although seen regularly by the Crisis Team, Mrs Mayer was seen by a number of different people as a result of which no trusting relationship could be established. She had to repeat her history at each visit to a different person about personal details.
(3) Different treatments were offered to Mrs Mayer without the reasoning or their efficacy being discussed with her.
(4) Mrs Mayer required help urgently on 14 November 2014 but due to an increase in demand no one was available to see her until 16 November 2014. It is understood Doctors are now called out and on Call Manager can be contacted in such situations.