Woman took own life after ‘no action’ was taken on mental health warning signs

Woman took own life after ‘no action’ was taken on mental health warning signs

12/14/2019

A woman took her own life after multiple mental health teams failed to act on warning signs she was planning suicide.

Maddalena Fiorello Beesley was found dead at home less than a week after her boyfriend flagged the deterioration of her mental health, Birmingham Coroner’s Court heard.

The 27-year-old librarian – known as Madi – had suffered depression since childhood, previously attempted suicide and was diagnosed with borderline personality disorder, Birmingham Live reports.

Boyfriend Paul Barnes had warned her therapist of his plans to end their relationship on August 15 – a move which could have increased her risk of suicide.

The mental health teams were aware Madi had taken an overdose following a previous break-up, the inquest heard.

But 'no action' was taken after Mr Barnes contacted them and the system at Birmingham and Solihull Mental Health Trust is now under review.


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Madi, who worked at the University of Birmingham, was found dead shortly before 9pm on August 21 at her house.

Area Coroner Emma Brown recorded a verdict of suicide and concluded there had been 'clear failings' at an inquest hearing on Monday (December 9).

Mr Barnes, who was also Madi's carer, expressed concerns on August 15, ahead of her final psychotherapy session.

She had been attending therapy for nine months with Laura Chaisty, a specialist psychotherapist and art psychotherapist for Birmingham and Solhull Mental Health Trust.

As a result of Mr Barnes contact, Miss Chaisty penned a lengthy email to the Community Mental Health Team as she was due to go away on annual leave for two weeks.

"I contacted the Community Mental Health Team to raise their awareness of Madi and to say that she may need extra support," she told the court.

"My sense was that Madi may make contact and that might raise further input from the Community Mental Health Team. I didn't feel that the level of risk was different.

"I did know there was a circumstance change which is why I raised their awareness of her."

Sharon Whitehead, a registered mental health nurse, picked up the email from Miss Chaisty but no attempt was made to contact Madi. A risk assessment was not looked at nor updated.

Mrs Whitehead told the inquest: "It didn't worry me at the time. When I read the email I thought it was for information only. But because she had her appointment [that day] I was confident that they would make that assessment and that judgement."

During the last session Madi expressed suicidal thoughts with her therapist – but Miss Chaisty said this was 'sadly normal for her'.

"It was difficult for her to feel vulnerable and ask for help. It was really difficult for Madi to reach out," she explained.

Miss Chaisty did not believe her risk of suicide was increased at that point and no further contact was made with Madi or the mental health team.

"It is with great regret that I did not feel there was an additional risk," she added, addressing Madi's family.

There were other concerns that Madi should have had a care coordinator to manage the two services and act as a support line – especially while her psychotherapist was away on leave.

This policy that every patient should have a coordinator is currently under review, the court was told.

Madi's mum Clelia Boscolo questioned why she was never contacted over her daughter's welfare concerns – and instead was only called two days after her death when it was too late.


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Mrs Whitehead added that it was "not something they would routinely do" and that they would need the permission of the patient to call next of kin.

Patrick Cullen of the Birmingham and Solihull Mental Health investigations team launched a probe into Madi's care following her death.

He concluded that there had been a "missed opportunity" by both the Community Mental Health Team and tertiary psychotherapy service.

"My finding was that the crisis care plan was not sufficient to support Madi through foreseeable and indeed predicted circumstances," he said.

"She should have been provided with details in the event that she needed further support.

"But in view of the clearly escalated risk, the plan should have been revisited with some perhaps more assertive steps to contact Madi directly to have a discussion with her about recent developments in her circumstances and how they may affect her in context of her history.

"The risk assessment should have been updated so it was more contemporaneous. There should have been an urgent review by a consultant or medic or perhaps a referral for support.

On what ought to be done in the future, Mr Cullen added: "There should be a collaboration between whichever services involved to identify needs and risks and agree a plan of care which would include a crisis response and that response needs to be individualised to that person."

If you need to speak to someone, Samaritans are available 24/7 by calling 116 123 or by emailing [email protected]

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