NHS trust has ‘not covered itself in glory’, inquest into vulnerable woman’s death told

An NHS trust has “not covered itself in glory” in its dealings with the family of a vulnerable young woman who killed herself after being refused admission to hospital, a coroner has found.

The original 2015 inquest into the death of Sally Mays (pictured), 22, was quashed by the High Court last year after the emergence of a conversation between one of Miss May’s care co-ordinators and a consultant psychiatrist on the day she died, which had been withheld from the original hearing.

On Wednesday, senior coroner Professor Paul Marks ruled that the conversation “was neither a clinical conversation nor an attempt to escalate (Sally’s) care”.

He said: “It was a conversation between colleagues in which the frustrations of the working day were vented.”

The coroner said the conversation did not represent a further missed opportunity to prevent Miss Mays’ death.

But, he said: “The trust has not covered itself in glory with regard to its dealings with the family and the disclosing of documents.”

At the start of the inquest, Professor Marks described how Miss Mays, who had long-standing mental health issues, died at home in Hull on July 25 2014, after she was turned away by the Humber NHS Foundation Trust crisis team earlier that day.

The coroner said the new proceedings would focus on the new evidence around a conversation in a car park between Laura Elliott, who had taken Ms Mays to hospital on July 25, and Dr Kwame Fofie.

On Tuesday, Ms Elliott told the court how she was upset when she approached Dr Fofie for “support and validation” shortly after she had been left “frustrated, angry and upset” because the crisis team had rejected her recommendation that Miss Mays should have been admitted.

Dr Fofie told the inquest: “This was a quick conversation in a car park with a colleague who was trying to ventilate.”

In her submissions to the coroner, Bridget Dolan, representing Miss Mays’s parents, Andy and Angela Mays, said that after hearing the evidence, the family accepted that the car park conversation “was not a clinical conversation” but that their concern was it “not coming to light” sooner.

Mrs Mays told the PA news agency the conversation emerged through a nurse who provided a supportive role to Ms Elliott following the inquest.

Ms Dolan told the hearing the family had requested details of the conversation from the trust once it came to light, but their application had been refused.

She said: “That is just no way to treat a bereaved family who are struggling to get the basic facts revealed.

“It is a sorry tale that the family have had to go through seven years of fighting to have this information, at their own expense.”

Michael Rawlinson, representing the Humber NHS Foundation Trust, said the trust “apologised unreservedly” for the fact that the car park conversation did not emerge earlier, and that a second inquest had been required.

Professor Marks previously concluded that the decision not to admit Ms Mays constituted “neglect” which bore “a direct causal relationship to her death later that evening”.

He said she was “inappropriately assessed” and not treated with appropriate “respect or dignity”, adding that if she had been admitted following an initial assessment or further “missed opportunities” she “would have survived and not died when she did”.

A further missed opportunity to save her life came from a 69-minute delay to an ambulance arriving after Ms Mays’s call was not categorised appropriately, the coroner said.

He concluded that Ms Mays’ actions, which included an overdose, “undoubtedly caused her death” but “her intentions remain unknown”.

After the conclusion of the inquest, Mr and Mrs Mays said: “This process has given us the opportunity to finally obtain and consider the details of information previously withheld from the first inquest by staff from Humber NHS Foundation Trust.

“Had this information been disclosed at the previous inquest seven years ago as it should have been, none of this tortuous process would ever have been necessary.

“All we have ever wanted is the truth about the circumstances of Sally’s death.

“However, none of this additional information was made available to us. Our only option in order to obtain it was to apply to the High Court for a fresh inquest.

“Significantly, at no time in the past seven years until today have we received an apology from the trust itself or the staff involved regarding the non-disclosure of information at the original inquest or the additional unnecessary trauma this has caused.”

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