NEGLECT, caused by repeated failures to assess a woman going through a mental health crisis, contributed to her death by suicide, a coroner has said in a report that is highly critical of the organisation that runs mental health care in Thurrock.

In a prevention of future deaths report Essex coroner Sonia Hayes said there were mistakes made at Essex Partnership NHS Foundation Trust (EPUT) that contributed to Mrs Jillian Steedman's death.

Mrs Steedman, 71, died on May 12, 2023, at Pitsea Station in Basildon after being hit by a train while she was "suffering a deterioration in her mental health".

In a prevention of future deaths report Essex coroner Sonia Hayes said there were mistakes made at Essex Partnership NHS Foundation Trust (EPUT) and Essex County Council that contributed to Mrs Steedman's death.

She had been discharged from a long-term mental health hospital to a care home on April 11, 2023.

EPUT's mental health services were informed by Mrs Steedman on April 15 that she wanted to end her life by 'jumping in front of a train'.

Her mental health continued to deteriorate in May, and this was escalated to mental health services on or around May 8, but they failed to respond.

By May 10, Mrs Steedman was in a mental health crisis, but mental health services again failed to attend and complete an assessment of her.

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Mental health services failed to complete a mental health assessment on May 11.

The next morning, she redirected a taxi to Pitsea railway station, where she died.

On April 27, the care home warned the mental health team and the council's social care team that there was a risk Mrs Steedman could divert a taxi to leave carers' supervision. However, this concern was not escalated, and no risk assessment was completed.

A statement from coroner Sonia Hayes said: "Mental health services failed to conduct a mental health assessment between May 8 and 12, 2023, when Mrs Steedman was suffering a deterioration in her mental health and was known to be in crisis.

"This was in the background of a known risk that a taxi could be diverted, and Mrs Steedman had expressed that she wanted to throw herself in front of a train and would find the train station. Care home staff had been instructed not to escort Mrs Steedman in the taxi and not to interfere with mental health plans. Mrs Steedman's death was contributed to by neglect."

Paul Scott, Chief Executive of EPUT, said: "I am sorry for the failings in Jillian's care and offer my deepest condolences to her family and loved ones, both personally and on behalf of everyone at EPUT."

A spokesperson for Essex County Council, which was also criticised for its failures, said: "We can confirm we have received the report and will be responding in full to the coroner within the timeframe provided."

EPUT is currently halfway through what is expected to be a two year investigation into its failings that contributed to thousands of preventable deaths.

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