An investigation into the death of a Wigan mother-of-two by mental health chiefs has resulted in an overhaul of their internal monitoring systems.
An inquest in Bolton heard Sharon Halliwell had not been referred to a psychiatrist following an assessment with an advanced nurse practitioner from North West Boroughs NHS Foundation Trust following an attempt on her own life.
The 48-year-old, of Manse Gardens, who had battled a longstanding sleeping pills addicition, alongside depression and anxiety, had scored highly on a standardised suicide assessment, the coroner’s court was told.
But as she had spoken positively about her future plans, including an upcoming holiday, and had no immediate thoughts of self-harm, nurse specialist Joanne Woodcock did not consider hers to be an urgent case.
She had also recently declared that she was free from her sleeping pills problems, which may have accounted for her low mood during the period, the inquest heard.
Mrs Halliwell, who grew up in Billinge, was found dead at her home on April 18 after her family became concerned for her welfare.
Bolton coroner Jennifer Leeming, after hearing from her husband Darren and medical staff, concluded that her death was a suicide.
And the coroner also expressed concerns regarding a lack of “connectivity” between frontline assessment workers and the psychological, after she was told Miss Woodcock did not have access to medical notes while conducting a weekend appointment at Lower Ince health centre,
John Walters, who conducted an investigation into Mrs Halliwell’s death on behalf of NWB, told the inquest there were now weekly audits, for ongoing cases, to improving monitoring of any outstanding appointments or similar requirements.
He said: “At the time of the incident there was no system in place to identify those referrals which had not been followed up on and there was no monitoring that would have helped to resolve this.”
Nurse Woodcock confirmed that staff now received a weekly email, questioning progress on outstanding cases, with further monitoring overseen by senior staff.
Mr Halliwell expressed concerns at the hearing that a number of opportunities to assist his wife had been missed over the course of her treatment.
The inquest heard that Mrs Halliwell had been in contact with mental health services since 2011 and had made previous attempts on her own life.
The hearing was also told of the couple’s volatile relationship, which had in the past included bouts of violence.
Darren was arrested in 2015 following an air-rage incident on a flight to America.
A court was told he’d assaulted his wife before screaming abuse at airline staff.