Mental health warning left ‘unread’ by staff day before mum took her own life

Marion Turner took her own life in January 2013.

The mum-of-four had been in and out of the Lakes Mental Health Hospital in Colchester, Essex, during the last few years of her life after suffering with her health for two decades.

But after being discharged for the last time in October 2012, Marion’s mum, Martha Hulme, claims she was only visited twice by her community psychiatric nurse (CPN) when she should have been visited weekly.

The day before she died, Marion’s solicitor had called the North Essex Partnership NHS Trust (NEP) with concerns for her welfare, but the message was left “unread” in someone’s pigeon hole until the next day – the day Marion took her own life.

Martha is now one of around 20 Essex families fighting for a public inquiry into the county’s mental health services in order to find “answers” for the failings they claim into their relatives’ care.

“She said she couldn’t cope”

Marion Turner suffered with her mental health for around 20 years

Marion had suffered with her mental health since her early 20s.

Due to her partner’s work, she would move from place to place, sometimes to other countries, and Martha claims she would often have to travel a long way to visit her daughter when she was suffering.

“She had ongoing mental health problems where she tried to harm herself, I would fly out to see her when she was in the hospital,” Martha said.

“When she had her first son, who’s 27 now, that’s when she had her first episode.

“She had sporadic times where it got worse, then sometimes she would be fine.”

According to Martha, Marion also had an eating disorder and she would self harm, but it was difficult to stay on top of her daughter’s condition from such a long way away.

Talking about one specific incident, Martha explained that Marion would often phone her when she was at her lowest.

“I would wait for the phone calls all the time,” she said. “One time she phoned me, which she did every time she did something, and she said she couldn’t cope and put the phone down.

“I kept phoning and got the police out. She nearly died and tried to do what she did when she died.

“She had bipolar and borderline personality disorder. It was like she wasn’t there when I went to visit her.

“It felt like I was working with one of my clients, I’m a counsellor, that’s what I was doing.

“I was in work mode.”

The fight for a public inquiry

In November 2012, Melanie Leahy’s son Matthew was found hanged at the Linden Centre in Chelmsford just a week after being admitted under the Mental Health Act.

She has been pushing for a statutory public inquiry, through which witnesses can be made to give evidence under oath, into the county’s mental health services ever since.

According to Melanie, it’s the only way the affected families will achieve justice for their loved ones.

There are now around 20 Essex families supporting the fight for an inquiry, all of whom have lost a relative during or after being under the care of a mental health service, but the number is growing.

The group has now secured the support of Hodge, Jones & Allen Solicitors who have agreed to work on a pro bono basis to try to secure a public inquiry.

Nina Ali, Partner at HJA, said: “HJA is intent on helping these families secure the justice that they deserve.

“It is essential to get to the truth of what happened – all those families whose loved ones died whilst they were under the care of Essex mental health services are owed answers for their loss.

“A public inquiry is needed to ensure that a comprehensive and in-depth investigation is carried out and those responsible are held to account. It is only then, that things can and will begin to change for the better.

“We urge all affected families and individuals to get in touch with HJA. The call for a public inquiry is to include everyone affected by the failings of Essex mental health services: families of children, adolescents, adults, and the elderly who have died and individuals who have been through ‘the system’ and suffered but survived.”

Priya Singh, Associate at HJA, claims: “It is not only families of the bereaved who are coming forward but also ex-patients from whom we’ve heard shocking reports of abuse suffered by the victims whilst in care. These stories are harrowing.

“Vulnerable people have entered what are meant to be centres of trust and safety – a number voluntarily submitted themselves for help – only to be abused and exploited by some professionals who should protect them.

“They come in with mental health issues and leave – if they leave – in a much worse off state than before.

“No family, no individual should ever have to go through that. These families have been failed by the organisations that are set up to treat and care for patients.”

“She could have still been alive”

Marion moved to Colchester a few years before she died and was admitted to the Lakes for the first time in 2010.

Martha claims she was taken in a few times over the next couple of years until October 2012, when she was discharged from the Lakes for the last time.

According to Martha, a care plan was drawn up following her discharge and Marion was meant to be visited by her CPN every week, a frequency that could increase if her mental health deteriorated.

But despite the care plan and the fact that Marion had “three or four” serious incidents of self harming during that period, Martha claims she was only visited twice in the three months before she died.

Evidence given at Marion’s inquest in 2014 confirmed that the day before Marion’s death, her solicitor, as a result of concerns about her mental health, had called the NEP’s office and left a message for Marion’s CPN.

The inquest report found that this message remained on a slip of paper, unread, in a pigeon hole until sometime the next day.

Martha claims that on the morning of her death, the CPN was informed that she had threatened her own life but didn’t call for a welfare check.

Martha said: “I feel strongly that Marion was let down in lots of ways regarding her mental health and I voiced that on many occasions to the professionals who were responsible for her care.

Essex’s mental health stories

“The day before Marion died her solicitor contacted the CPN’s office to inform him that she needed to speak to him regarding Marion’s mental health.

“He was on a call so a message was left in his pigeon hole which he did not pick up and 12 hours later my daughter was dead. 

“She could have still been alive.”

In the ‘report to prevent future deaths’ published after Marion’s inquest, seen by EssexLive, Senior Coroner Caroline Beasley-Murray said she believed there was a “risk that future deaths will occur unless action is taken”.

An Essex Partnership University NHS Foundation Trust spokesperson said: “We extend our deepest sympathies to Marion’s loved ones.

“Our electronic patient record systems now allow staff to send an urgent notification about a service user to the patient’s clinician and care team, enabling us to put support in place when needed. Since EPUT was established in 2017 our top priority has been to continuously improve patient safety.

“We continue to cooperate fully with ongoing investigations into the care of patients under the former North Essex Partnership University NHS Foundation Trust.”

“She went into a place of safety to be looked after”

Marion, who was 40 when she died, had four children

During Marion’s time in the Lakes, Martha claims she was left with a laptop charging cable and a glass photo frame, items she believes her daughter shouldn’t have had access to considering her mental state.

She also claims that Marion was on suicide watch at the time she was released from the Lakes in October 2012.

The last seven-and-a-half years have proved a hugely difficult time for Martha in trying to come to terms with her loss, but it’s made her more determined to fight for change in the mental health system.

“Losing Marion affected me enormously,” she said. “I ended up having to take anti-depressants, something I never thought or wanted to take but losing Marion broke me.

“I was diagnosed with PTSD and I am still presently having ongoing therapy nearly eight years later.

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“I am still angry as I tried for four years to get answers, so the only way families like myself will get answers is with a public inquiry.

“That’s what I spent four years fighting the NHS for.

“Marion was very vulnerable in that way, she was lacking in confidence.

“She went into a place of safety to be looked after and they didn’t do it, even in the community they didn’t do it.”

Essex Live