Mental health care criticised after A12 death

A CORONER has raised concerns about a “gross failure” to provide care for a mentally-ill woman who died just hours after being told there were no consultants to assess her.

Elliot Furniss

A CORONER has raised concerns about a “gross failure” to provide care for a mentally-ill woman who died just hours after being told there were no consultants to assess her.

An inquest, held at Endeavour House in Ipswich yesterday, heard that Karen Crews, 50, died from multiple injuries sustained when she was hit by a lorry travelling along the A12 near Capel in May last year.

Mrs Crews, who lived in Rayleigh, Essex, had seen her mental health decline in the preceding year, making two suicide attempts and spending nearly two months as an inpatient at Runwell Hospital in Wickford.


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The inquest heard that on Monday May 12 she once again seemed “delusional” and had handed her son a knife, asking him to “finish her off”.

Her husband Steve told the inquest that later that day he went alone to the nearby Coombewood Mental Health Resource Centre seeking help.

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He said he was told by the duty officer, an experienced mental health nurse provided by an agency, that there were no consultants available for 48 hours.

An emergency appointment was made for Wednesday May 14 and Mr Crews was told to take her to hospital in the event of an emergency.

But the following day Mrs Crews left her home and drove up the A12 into Suffolk, parking her car in a lay-by.

The inquest was told that at about 9.45pm she was hit by the lorry while her body was in an “almost horizontal” position, however the coroner ruled that he could not be sure that she had intended to kill herself.

While giving evidence, both Dr Claudio Ague, Mrs Crews's consultant, and Tracey Wright, a senior manager for the Crisis Resolution and Home Treatment Team, which had treated Mrs Crews, agreed that she should have been fully assessed when Mr Crews first made contact.

Mrs Wright said the service was now “much more robust” in many respects and agency staff were no longer being used.

Dr Peter Dean, coroner for Suffolk, said he was satisfied in his own mind that there was a “gross failure” by South Essex Partnership University NHS Foundation Trust to provide appropriate care.

But he explained to the family present at the hearing that the evidence available to him limited his ability to record anything other than an open verdict.

He added: “Things have come out of this inquiry to minimise the risk in the future. There were concerns about the initial contact and concerns about the information given to the family.

“There were clearly communication and triage issues and clearly concerns about the accuracy of the notes that were kept.”

Dr Dean said he would be sending a transcript of the inquest to Dr Patrick Geoghegan, chief executive of the trust, and to the Nursing and Midwifery Council.

After the verdict, Mrs Crews's brother Gary Nicholls said he hoped lessons could be learnt from the tragedy.

He said: “What we hope is that other people can be prevented from going through this suffering.”

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