Tragic death of 'remarkable' Wigan mum after trauma and complex mental illness

An inquest at Bolton Coroner’s Court heard the 35-year-old woman – who cannot be named for legal reasons – had faced mental health problems for many years and was diagnosed with both emotionally unstable personality disorder and complex post-traumatic stress disorder (PTSD).

She was sexually abused as a child and was again abused as an adult by a mental health professional who was supposed to be caring for her, which led to a lengthy legal process in the High Court and an overhaul of her care.

The woman also had a lack of “meaningful contact” with her daughter, something the court heard affected her “very deeply”.

Coroner Simon Nelson was told the woman was “very bright and clever”, had graduated from university and was working.

But she had a long history of self-harm and suicide bids, which were described as attempts for her to “reset” when she was struggling with her mental health.

She knew she was “rolling the dice” and these episodes of self-harm could have serious consequences, the court heard.

The time between these incidents became longer in the period before her death, as she worked closely with a new team of mental health professionals.

The court heard she was “determined” to improve her life, had goals and aspirations, had a good relationship with her partner and was focused on work.

Consultant psychiatrist Dr Faheem Naqvi said she was “making really good strides forward”, was being given more autonomy over her medication, socialising more and was moving towards losing the diagnosis of emotionally unstable personality disorder.

He said she had faced “multiple traumas” and felt a “sense of injustice” after being abused, so it “meant a lot to her” when she won the High Court case, though she did lose having something to focus on.

Trauma psychotherapist Dr Elizabeth Royle said it was “tricky” when she started working with the woman, due to her past experiences with the mental health system, but they built a “really strong relationship” and she made good progress.

Last summer she was “really empowered and in a really good place”, but the woman started to “slowly slide” in the following months.

She seemed “absolutely exhausted” in October as she was struggling to sleep and was dealing with stressors including the lack of contact with her daughter.

The court heard she was “pushing away” some mental health professionals, so Dr Royle encouraged her to accept their support.

Members of her health team spoke about her deteriorating mood and how they could help her.

The woman finalised her will, but told mental health professionals it was an outstanding task and she did not have suicidal thoughts.

However, the inquest heard the woman told her partner she was going to play bingo with a friend two days later, but she instead drove their car to Marus Bridge and parked up.

She knocked on the door of a HGV and had a brief conversation with the driver, asking if he was staying there for the night, before returning to her car and driving away 30 minutes later.

The driver noticed the car return later and park slightly further away.

He realised afterwards that something was wrong and went to the car, where he found the woman slumped over the steering wheel and could not rouse her.

He phoned 999 and she was taken to Wigan Infirmary by ambulance, but she could not be revived and was confirmed to have died shortly afterwards.

A post-mortem examination found she died by carbon monoxide poisoning. The only drugs found in her system were prescribed medication.

A police investigation did not find any suspicious circumstances surrounding her death.

Dr Royle said she did not know what else could have been done to help her patient, who she described as a “remarkable young woman” but she wished “there was something we could have done”.

After hearing all of the evidence, Mr Nelson said: “I have never come across a case like this before. I have done hundreds sadly, possibly even into four figures, of cases of self-harm, but none with the intricacies that this case has exhibited in the course of both the reports that I have read and the oral evidence that has unfolded. It is quite unique.”

He said it was clear the woman took her own life, but he had to consider if she intended the consequences of her actions, particularly given her “background of extensive self-harm”.

But he was persuaded that she did intend to end her life when he heard she had left messages detailing funeral arrangements and plans for her estate.

He concluded she died by suicide and stated a list of matters that he believed “more than minimally” contributed to her vulnerability and the decision to end her life.

These included the sexual abuse she endured, her perceived failure of the police and local authority to investigate it, her concerns about safeguarding after the abuse and the duration of the legal action that followed. He also listed the lack of contact with her child and her perceived failure of the family court system.

The woman’s relatives thanked the people who cared for her for their efforts.

If you need to speak to someone, call Samaritans at any time on 116 123.