Another life lost after mistakes made and failings with NSFT’s crisis line and gaps in services.

Mrs Maggie Harvey, 67, sadly died in her home whilst experiencing a mental health crisis. Mrs Harvey had moved from Suffolk to Norfolk, therefore moving from the Bury St Edmunds community mental health team in Suffolk and was reluctant to accept care from the Norwich team. The inquest uncovered her move caused miscommunication, confusion and delays in her mental health care, even though both of the counties are run by the same organisation, Norfolk and Suffolk NHS Foundation Trust (NSFT).

Mrs Harvey was discharged, with her agreement but was advised on how she may access help if she needed it. However, when that time did come, her referral was refused. This was due to the trust thinking the referral came from a GP, but it came from the trusts mental health nurse working within Mrs Harveys local surgery. The letter Mrs Harvey received from the trust refused the referral to re-access care and recommended she see the very nurse who made her referral.

The inquest considered if the miscommunication had not happened, it may have meant that Mrs Harvey would have been accepted onto the Norwich team, yet that would have meant she still would have had to wait 28 days.

9:58pm. days after the letter was sent – Mrs Harvey rang 111 Opt 2 (the old first response crisis line)

This call lasted 48 minutes, in which Mrs Harvey disclosed to a crisis care practitioner that she could not keep herself safe. The call resulted in the suggestion of a referral to NSFT crisis team which would visit her in 4 hours. Mrs Harvey declined that as she felt she could keep herself safe for that amount of time.

Approx 10:40pm. After the call ended, the handler immediately called 999 for an ambulance to attend Mrs Harvey’s Norwich home.

Due to ambulance pressure, a call back would take six hours, and an ambulance would take 12 hours to attend. Christopher Hewitson, a patient safety officer at the EEAST (East of England Ambulance Service Trust) disclosed that the call was categorised as the lowest priority, a category five.

12.56am. A clinical from EEAST attempted to contact Mrs Harvey but could not reach her, resulting in the call being escalated.

3.38am. On March 14th paramedics reached her home and found her unresponsive.

David Hannant adds his analysis on his article in Eastern Daily Press:

Maggie Harvey’s case is a heartbreaking one to report – but one that is incredibly important. The tragedy highlights the fractured nature of mental health services, particularly in our region and raises a number of pertinent questions.

While it is important to point out these things are very easy to say with the benefit of hindsight, it certainly appears to be the case of a woman who desperately wanted help – but could not get it. This is why it is vitally important that lessons can be learned from her case.

Perhaps the most pertinent matter arising from the inquest though is the need for clarity over the emergency response to people in mental health crisis – an issue that has been hugely topical in the light of last month’s killings in Costessey and the decision by the police to pause its ‘Right Care Right Person’ policy.

During the hearing, it was emphasised how difficult it can be to assess the urgency of mental health crises. It is true to say that psychological trauma does manifest itself differently from physical and the latter is clearly more straightforward to spot accurately.

And therein lies a huge part of the issue with a system in which mental and physical have to compete against one another for priority.

This is what makes the coroner’s comments on there being a need for specific emergency response provisions for mental health crises. Cases like Mrs Harvey’s tragically emphasise that while there continues to be ambiguity over just who responds to these people in their urgent moment of need, people will continue to die.

It also emphasises key issues still facing the region’s struggling mental health trust in terms of how it not only communicates with partner organisations – but different parts of itself. On the surface, mental health nurses being accessible to GP surgeries is a fantastic idea and indicative of efforts to make primary and specialist care work closer together. And this is absolutely vital across all health services, from hospitals to GPs, to mental health trusts, to social care. But, sadly, until these organisations start singing from the same hymn sheets, confidence in services will remain low.

The inquest revealed ‘gaps in services’ as Mrs Goward, the coroner, explained this case uncovered concerns about how mental health emergencies are handled. She said: “There are a few areas of concern and it feels to me that there is a gap in services.

“My concerns are in terms of mental health patients and their needs if there are not emergency services available.

“If there is a risk to their safety they do not have a specific emergency service – and who fills that gap.” However, the article explained that within the inquest there was evidence to show ongoing work to address these issues including a rapid response car specifically for mental health crises. There is a worry as the car is only available between 1pm and 1am.

There is a consideration by Samantha Howard about writing up a prevention of future death report on this case (PFD) depending on further evidence that will be presented by the trusts.

David Hannant’s article gave a tribute from Mrs Harveys family:

In a statement issued following the inquest, her four children – Liz, Will, Ed and James said: “Maggie Harvey was a beloved mother and grandmother to her six young grandchildren. She was a passionate mother and grandmother, her family were the most important thing in the world to her.”

“She was also an incredible friend, always there in times of need and always there to put smiles on people’s faces. She had a huge network of friends who were there for her through the good and bad times.”

“She had an infectious laugh and the ability to touch people’s lives more than she ever realised. Despite her challenges mentally and physically, she was a fun-loving, outgoing lady who showed incredible resilience, strength and bravery.”

“She is hugely missed. We as a family would like to thank the coroner for highlighting the issues that contributed to her death and we hope to see changes in how mental health emergencies are dealt with in the future.”

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