Rosie Fender: Health Trust issues apology after Inquest conclusions criticise Rosie’s care
Rosie Fender died, aged 26, on 3 February 2022. Rosie took her own life, after suffering from long term and serious mental ill-health, after having experienced significant trauma during her childhood.
HM Area Coroner Rosamund Rhodes Kemp recorded a conclusion that Rosie’s death may have been avoided if a holistic treatment plan been put in place for her, or, even if more support had been provided to her and the people trying to care for her, in the weeks prior to her death.
The narrative conclusion recorded that whilst under the Trust’s Community Mental Health Team (CMHT), Rosie had no comprehensive Care Plan, Care Coordinator or diagnosis due to the Trust’s “inadequate resources / systems” for managing patients, such as Rosie, at the relevant time.
An independent consultant forensic psychiatrist gave evidence that “passing” Rosie between teams without a care coordinator caused “major difficulties” in her care and assessment, that her care was “extremely disjointed” and that the Trust’s principle of the ‘no wrong door’ approach had “clearly” not worked in her case.
Rosie’s mum described her as a bright star who could light up any room. She was creative, loved dance and music and cared deeply about all animals.
Background
In April 2021, Rosie was first referred to the Southern Health CMHT after reporting suicidal thoughts, intrusive abuse from a voice in her head and auditory, tactile and visual disturbances of an evil spirit / demon which attacked her at night and prevented her from sleeping. She reported feeling as though she had not slept for two years and that she did not have the strength to carry on. She had a previous diagnosis of OCD and was often unable to leave her house, allow others into her house or make and/or touch her own food due to a fear of contamination.
Rosie was reliant on a man (NH) (described sometimes as her friend and/or carer) to provide her with daily care, including to bring her food and support her to take medication. NH had previously been convicted for sexual offences against Rosie when she was a teenager, and when he was her teacher at school. NH had made clear to the Trust that he struggled to cope with the severity of Rosie’s symptoms and needs, having no training and little support.
The absence of a comprehensive care plan
It was accepted by all the psychiatrists who had assessed Rosie, and by the independent expert who gave evidence at the Inquest, that Rosie required a comprehensive, coordinated and consistent treatment plan, which would involve allocation of a care coordinator and a referral for trauma informed therapy.
Rosie was, however, never given a formal diagnosis and at the time of her death, had still not been referred for therapy.
In May 2021 and August 2021, she had twice been referred to the Trust’s Early Intervention in Psychosis (EIP) Team for assessment and, potentially, treatment for psychosis. It was established at the Inquest that the EIP team were the only team at the relevant time with the resources to provide the care Rosie needed. After both referrals, however, Rosie was discharged from the EIP team without a face-to-face assessment and was referred back to the CMHT.
The independent expert gave evidence that the EIP team’s assessment of Rosie was “inadequate”, did not comply with NICE Guidelines and that she was done a further “disservice” because their assessment was described as “detailed” and “extended”, when “clearly” a detailed assessment was not carried out. This inadequate assessment was used to “overturn” the considered view of an experienced consultant psychiatrist that Rosie might have been suffering from psychosis.
After re-referral to the CMHT, Rosie was placed on a waiting list for a care coordinator, who was finally appointed some 9 months after she first entered the service and less than a month prior to Rosie’s death. In the meantime, Rosie, her mum and NH made frequent and increasingly desperate calls to the Trust requesting help to support her to sleep, stop the voices in her head and because Rosie felt suicidal due to her symptoms. HM Area Coroner recorded that during this time, Rosie’s care consisted mainly of medication reviews instigated by Rosie herself.
In the month prior to her death, Rosie was forced to move to a new home. It was also communicated to her that she would need to register with a new GP and transfer to a new CMHT as she now resided in a new catchment area. Her mum reported significant concerns about this to the Trust. On the day prior to Rosie’s death, her mum called the Trust to say Rosie was likely to kill herself, and that she was unable to cope with the move to a new GP and new CMHT, alongside ongoing difficulties with her house move and on top of her longer-term struggle with severe mental-ill health. The Trust did not, however, deem Rosie’s level of risk to herself to have changed.
Apology by the Trust
Southern Health NHS Foundation Trust is now part of Hampshire and Isle of Wight Healthcare NHS Foundation Trust. Following the conclusion of the Inquest, Dr Daniel Baylis, chief medical officer at Hampshire and Isle of Wight Healthcare NHS Foundation Trust, acknowledged the Coroner’s findings and said: “We recognise that there were aspects of Rosie’s care that did not meet the standards expected, and for that we are truly sorry”.
The Coroner continues to consider whether to make a prevention of future deaths report.
The family were represented by Hannah Smith, instructed by Gimhani Eriyagolla at Hodge Jones & Allen.
Further coverage of the Inquest can be found here:
If you are feeling low, Samaritans are here – day or night, 365 days a year. You can call them for free on 116 123, email them at jo@samaritans.org, or visit www.samaritans.org to find your nearest branch.
