Mental health trust failed Romford mum who jumped to her death from shopping centre car park, inquest hears
PUBLISHED: 12:00 25 January 2019 | UPDATED: 12:22 25 January 2019
The death of a mum who jumped from a Romford multi-storey car park could have been avoided if she received the mental health care she needed.
Karen Coles, 49, of Dickens Way, suffered fatal injuries after falling from the Liberty Shopping Centre’s car park, in Western Road, on July 15 last year at around 1pm.
Her husband, Steven Coles, had taken Karen out shopping that day.
Feeling unwell, she waited outside on a bench while he entered a shop to get a few items.
But Karen was gone by the time he returned.
Her body was found by the shopping centre’s cleaning supervisor in an alleyway nearby and she was pronounced dead by paramedics at 1.40pm.
An inquest held at Walthamstow Coroners’ Court yesterday (January 24) found that evidence could not reveal Karen’s intention at the time of her death.
“There was no note,” said senior coroner Nadia Persaud. “I consider that her actions were impulsive and I cannot make a finding in relation to her intention.”
However numerous failings were identified in the care Karen received in the weeks leading up to her death.
“I find that, on the balance of probabilities, had Karen received the mental care she required, her death on July 15 would have been avoided,” Ms Persaud said.
“I make this finding on the basis that when she had suffered her previous relapse [in 2015], in-patient care and psychiatric assessments had helped her to recovery.”
The mother-of-four had suffered from a hormonal imbalance, depression and anxiety with associated psychosis – for which she was taking medication.
In June last year, with the approval of her GP Dr Heerah, she stopped her hormone replacement therapy due to concerns about thrombosis.
But she began to experience panic attacks and low moods.
On July 1 - two weeks before she died - Karen was rushed in an ambulance to Queen’s Hospital A&E after having taken an overdose of prescribed antipsychotic drug quetiapine.
It is not known how many tablets she consumed “but it must have been substantial”, the coroner determined, as she did not recover from her drowsiness for 17 hours.
Karen was seen to by two mental health nurses, only one of whom was identified on records – Mr Muchopa.
The coroner ruled her overdose “was of significant gravity to warrant a detailed mental state examination”, but none was conducted nor did a risk assessment take place.
The nurses also did not fully document the assessments they did carry out nor inform Karen’s mental health liaison team (MHLT) or GP of her overdose.
Dr Heerah learned of the overdose when Karen visited her three days later.
Karen told her “she did not want to commit suicide, but she wanted the panic attacks to stop”.
The GP urgently phoned and faxed nurse Victoria Chime of the North East London Foundation Trust (Nelft) to inform her of the situation.
Ms Chime then called Karen the same day, who told her she “was now feeling better and wanted to rest”.
The nurse assessed Karen’s risk of suicide as “low”, despite the GP’s concerns, citing that Karen denied having suicidal thoughts and her family was considered a “protective factor”.
But in court she acknowledged that she could not conduct a full mental state examination over the phone or determine if Karen was downplaying her symptoms.
She also had told the court she did not look at Karen’s records before speaking to her or concluding her assessment because “lots of other calls came in”.
The nurse was described by the coroner as “a relatively inexperienced nurse” who had worked within the community mental health team for only five months at the time she took responsibility for Karen’s care.
She also did not complete Karen’s risk assessment until July 24 – after she had learned of her death.
Karen’s mum Sandra Branch contacted Ms Chime again by phone and email on July 9 and 10 - raising concerns about her lack of sleep.
But no action was taken to arrange an face-to-face assessment or clinical team meeting review.
Concluding, Ms Persaud said: “Between July 1 and July 10, assistance had been requested from the mental health services, by Karen’s GP and Karen’s family.
“Despite the requests and the clear need for clinical assessment, Karen was not fully assessed by the mental health team prior to her death.
“A fully informed treatment plan was not in place by the mental health service.”
Ms Persaud said she would not write a regulation 28 “preventing further deaths” report as she was satisfied with a number of changes Nelft has made to its practices in response to Karen’s death.
Speaking after the inquest, mum Sandra said: “I feel very annoyed by the fact that everything could have been avoided. We were such a close family.
“The main thing now is getting changes in place that might help other people.
Sister Lisa Sullivan said: “We emailed and phoned but did not get a reply. Where was the out of office reply? Why didn’t it get forwarded on?”
“You’re not dealing in a shop, you’re dealing with people’s lives.”
Karen was described by her mum as a “bubbly, funny, happy-go-lucky girl”.
She spoke of how friends and family helped to raise more than £9,000 for mental health charity Mind in her honour.
More than 200 people attended her funeral,she added.
She had previously worked as a teaching assistant at Marshalls Park Academy, in Pettits Lane.
The Samaritans charity is available 24 hours a day to provide confidential support for people who are experiencing feelings of distress, despair or suicidal thoughts. Call 116 123.
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