Inquest hears of ‘systemic failure’ in care of woman

A DOCTOR has said a systematic failure led to the death of a woman just a matter of hours after she was described as being a “high risk” of self harm.

The inquest into the death of Elizabeth Fuller was told that attempts to admit her to hospital under the Mental Health Act on February 7, 2011, failed due to mixed messages by health professionals.

The 61-year-old, who had a borderline personality disorder with psychotic episodes, was first seen by police at 2.13am on the day at her home in Main Crescent, Wallsend, after a call to say she had cut her wrists.

However, members of he Crisis, Assessment and Home Treatment (CAT) Team did not attend the address following a request by paramedics.

A GP from Northern Doctors, Dr Alan Whitmore, was called out the next morning, who regarded her as high risk.

But when he contacted a psychologist he was told to ask the police to take her to a cell – something they had no power to do.

When members of the CAT team arrived to assess her a few hours later, they deemed her to be low risk.

Dr Whitmore said: “She was the unfortunate victim of a systemic failure and I hope lessons are learnt from this.

“She was suffering acute psychotic symptoms, delusions and hallucinations.

“She believed the devil was planning to snatch her and take her to hell.

“I was hoping I would get a proper mental health professional to come to the house, I wanted a mental health assessment to take place as soon as possible as she wasn’t safe.

“There was a very serious risk of serious harm and that was aggravated by her psychotic episode.

“I didn’t feel we were doing the best for this lady.

“It was very upsetting to not have your diagnosis taken seriously and I was worried there might be adverse consequences to that.”

The CAT team returned to her address that afternoon and at 11am the following day, but got no response.

When they returned again at 4.30pm on February 8, they tried the door and found Ms Fuller dead in the kitchen.

The inquest heard how a funeral payment plan had been found near her body.

Pathologist Rachel Bolton said she had died from blood loss following 128 stab wounds.

“This case has the most number of stab wounds and knife related wounds that I have ever seen,” she said.

Injuries to her hands where she had been holding the blade to inflict the wounds, upgraded the post mortem from a routine to a forensic examination.

Ms Fuller’s sister Margaret Hall said: “She tried to commit suicide many times throughout her life, the last time I said if you ever decide to take pills again, phone someone else.

“I have lived with that for years because this time she phoned the ambulance service.

“I wonder if it would have been different if I hadn’t have said that and she had rang me.

“You can’t help but say ‘what if?’

“I wouldn’t have expected her to do what she did. Until she could get a new supply of pills, I would have assumed she would have been ok.”

Recording an open verdict, North Tyneside deputy coroner Paul Dunn, said: “I can’t be satisfied when she inflicted these injuries, whether they were inflicted in one go in a frenzy, or over a period of time.”

He praised the health professionals involved in Ms Fuller’s care, saying that those who found her happened on “a horrific scene.”

“The CAT team provide a very important function, it’s not always the correct function and on this occasion it turned out not to be,” Mr Dunn said.

He insisted there was no suggestion the service had let her down, but said there had been “errors in terms of communication”.

“There is a need, for relationships to be developed between each of the parties who were involved in this case,” he said.

Mr Dunn said that he had expressed concerns about the visits to Ms Fuller on February 8.

However, he believed the service had accepted that a different course of action may have been more appropriate, which was shown by them introducing a new protocol.

“I have heard that lessons have been learnt as a direct result of the death of Liz Fuller,” he said.

“This was unexpected and it was as tragic a way as a person can bring their life to an end.”