'Missed opportunities' to provide extra help for Wigan mum struggling with mental illness

Coroner Peter Sigee believed more could have been done to help Kerry Carruthers – but he could not say the missed opportunities would have prevented her death at the age of 45.

She died just 10 days after being discharged from a mental health unit, where she was being treated for severe depression.

An inquest at Bolton Coroner’s Court heard mum-of-two Mrs Carruthers was a nurse – a career she loved – and had been working as a sexual health nurse at the Shine Centre in Wigan town centre for 12 years.

But last spring she woke her husband Stuart one night to tell him she could not face going to work as she was unhappy.

This led to her realising she needed to get help, after previously being diagnosed with depression.

She saw her GP and a counsellor and took time off work, with her family rallying around to support her.

Mrs Carruthers returned to work, but her mental health deteriorated further after a few weeks.

She had regular appointments with her GP surgery, often by telephone, and reported medication did not seem to be helping.

Mrs Carruthers, who lived in Gidlow, sought help from the crisis team and was assessed.

But she continued to struggle, saying she felt detached and later revealing suicidal thoughts.

Mr Carruthers told the coroner his wife made an attempt on her life and while the crisis team told him to take her to A&E, staff at the A&E unit said she would not be seen there.

The crisis team assessed her and a decision was made for her to be admitted to an inpatient unit.

After initial difficulties with finding a bed, she spent two days at a unit and then left, before going to Atherleigh Park hospital in Leigh on October 16 with severe depression.

Mental health nurse Abbie Johnson said Mrs Carruthers was “quite anxious and low” at first, but spoke openly and engaged with staff.

Changes were made to her medication and she attended sessions with psychologists.

Mrs Carruthers left the hospital on November 1 and while she still felt “low”, she was “optimistic” about working to feel better.

The inquest heard she was a voluntary patient and could leave when she wanted to, but consultant psychiatrist Dr Georgy Pius was satisfied she could leave then and get support in the community.

But Mrs Carruthers’ family raised concerns about the care provided to her at home, reporting appointments being cancelled or staff not turning up.

Dawn Senior, senior nurse practitioner with the crisis team, told the inquest about a visit to Mrs Carruthers’ home on November 8.

Mrs Carruthers described feeling low but wanting to get well and they spoke about a range of issues, including her guilt at not working, symptoms of depression and how to manage them, and setting small goals. She had “fleeting” thoughts of suicide but no plans to act on them.

Ms Senior said they discussed the frequency of contact with the crisis team and Mrs Carruthers did not believe she needed daily visits, with arrangements made for visits and phone calls on alternate days.

Nurse Shirley Myers made telephone contact with Mrs Carruthers on November 11 and said she felt “really anxious” and “very overwhelmed”. She denied having thoughts of harming herself and was frustrated about being off work.

They discussed medication and Ms Myers ensured she had relevant phone numbers if she needed any further support.

The inquest heard Mrs Carruthers spent time with her mother Kathleen Featherstone that day and seemed to be quieter than usual, returning home at 3.30pm.

Her husband got home an hour later and found her unresponsive. He called 999 and paramedics quickly arrived, but Mrs Carruthers was confirmed to have died. A note had been left for her family.

A post-mortem examination found she died by hanging. Tests showed she had taken anti-depressants as prescribed, but no other drugs or alcohol.

An investigation was carried out afterwards to look at the care provided to Mrs Carruthers by Greater Manchester Mental Health NHS Foundation Trust.

Consultant clinical psychologist Lee Fitzpatrick told the inquest there had been regular risk assessments, discussions about suicide and evidence of interventions.

But there were shortcomings with the care provided, including a reliance on making contact by telephone and issues with pulling together information.

He explained visual cues could be missed during telephone calls, which could be seen when meeting in person.

Mr Fitzpatrick said: “People tend to communicate differently, which we have seen over the Covid period. That, combined with limited opportunities for families and carers to feed back their perspective as well, meant that there were limitations in those assessments.”

He found there was a need for senior managers to review staff compliance with risk assessment training, a look at the frequency of telephone contact rather than face-to-face appointments, and records should be kept on why home visits were cancelled.

He suggested care plans and documents should be provided to service users, along with a breakdown of steps to take if their risk increased.

There should also be a review of guidance given to people about when to go to A&E and when to get other professional support to prevent mixed messages.

After hearing the evidence, Mr Sigee said: “At the time of her death, Mrs Carruthers was affected by mental ill health. Mental health services missed opportunities to provide additional support to Mrs Carruthers in respect of her known mental illness, but it cannot be determined this additional support would have prevented her death.”

He felt unable to conclude that she died by suicide, instead recording Mrs Carruthers died while affected by mental illness.