Sunday Times – Mother’s Pain at lost chance to stop suicide

Article by James Gillespie Published: 09 March 2014.

The mother of a vulnerable anorexia sufferer sent to a private hospital because no NHS beds were available near her home has described the torment of thinking she had missed a chance to save her daughter from taking her life.

Lisa Inkin, 21, died last April when she jumped in front of a Tube train at 10.28am at Victoria station in central London. She had texted a suicide note to her mother, Sherry, 11 minutes earlier but it did not arrive until 10.40am, by which time Lisa was dead.

Sherry, 52, has since seen CCTV images of Lisa on the platform. “She looks focussed, just staring straight ahead of her, just totally switched off,” she said.sherry

“I found it reassuring because, as I didn’t reply to her text message, I kept having this image that she would be standing there looking at her phone, waiting for a reply.

“But she wasn’t, so from that aspect I found it quite comforting. She obviously sent the messages and then put the phone in her pocket.”

The tragedy for her family is all the greater for Lisa having only been at Victoria station because there were no psychiatric beds available for her in Kent.

Lisa, who lived in Gillingham, was being treated at a private eating-disorders facility at the Cygnet Hospital Ealing, west London, about 50 miles from her home. Hers is the latest case to highlight problems associated with the loss of mental health beds across the country, and the use of out-of-area facilities.

Fiona Wilcox, the coroner at Lisa’s inquest, raised concerns about the shortage of such beds in Kent. The number of acute mental health beds available in the NHS has fallen by at least 1,700 — around 9% — since April 2011, and average occupancy levels are running at 100%. Wilcox also expressed concern about the lack of response by the Cygnet staff after they were told that Lisa was expressing suicidal intent.IMG_0075

On the evening before Lisa’s death, a friend had called the ward at Cygnet to warn that Lisa was suicidal. No action was taken that night and Lisa’s mother was not called until the following morning, when Lisa had already left home.

“If they had told me, she wouldn’t have been travelling back [alone], I would have gone with her,” said Sherry. “There was an opportunity to save her and I never got the chance.”

It was when Lisa was returning to Ealing after home leave that she texted friends and family, warning of her intention to take her own life.

“She didn’t say how in the text, but said it was going to be hard to do,” said Sherry. “The last time she took an overdose she said, ‘It made me so ill, I’m not going to do that again’. Stupidly, I thought that meant she would never try suicide again. It never occurred to me she would look for a different way. She made sure, this time, that she couldn’t be saved.

“It will happen again if they keep ferrying people half way around the country — people who are already distressed and distraught and are then moved away from their family.”

Lisa, a veterinary assistant for the People’s Dispensary for Sick Animals, developed anorexia in 2010, three years after she was raped by a stranger. Sherry believes the incident sparked her illness, and psychiatrists failed to properly treat it. At one stage Lisa, who was 5ft 3in tall, weighed just 4st.

IMG_0004Sherry is now taking legal action under the Human Rights Act against the Kent and Medway Partnership Trust, and Cygnet. Her solicitor, Nick Fairweather, a medical negligence specialist based in Whitstable, Kent, said: “They are closing so many of the acute beds and are saying it will be much better for people to be cared for in the community, but some people are so unwell they need to be in hospital.”

The Medway Clinical Commissioning Group said there are plans to increase the number of mental health beds in Kent by 14, to 174.

Cygnet Hospital Ealing said changes had been made, including a reminder to all staff to “escalate information” received about patients and ensure that those on leave are contacted every 24 hours.

Commenting on the claim that the hospital had failed to alert Lisa’s family after her friend’s phone call warning the ward she was suicidal, a spokeswoman said: “This [call] was recorded and dealt with by the Ward Manager, who contacted the mother and spoke to Lisa the next morning, and to the police to alert them to our concerns.

“The coroner commented that Lisa may have been planning her death for a little while and even if contacted may have continued to do so.”

Reproduced with the kind permission of the Sunday Times.