Mental health staff refused to upgrade the risk level of a woman who repeatedly asked for help despite overdosing and self-harming, an inquest into her death has heard.

Linda Banks, 48, from Ferryhill, died in hospital on April 10, 2022, after taking an overdose. In the months before her death, she had been a patient of the County Durham and Darlington Crisis Team.

The crisis team is intended to offer urgent support and care to adults who are experiencing a mental health crisis. It is run by Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV).

Now, it has emerged that Linda contacted the crisis team up to four times a day from February 2022 to her death in April 2022.

The inquest, held in Crook today (Tuesday, November 21) was told that despite her pleas for help, the crisis team staff did not think that she posed more than a “low risk” to herself and failed to refer her towards specialist teams that could have helped. 

The Northern Echo: Linda Banks died in 2022.

Her mental health deteriorated in spring 2022 following the death of her mother, after which Linda struggled to look after herself and her home, not eating or drinking for long stretches. Before she died, she told police she had not eaten for seven days.

Multiple agencies – including her GP and housing group had contacted the crisis team over concerns for her wellbeing.

Her family had also contacted the crisis team for assistance after noticing a “significant deterioration” in her mental health in the weeks preceding her death.

This was during a period when the crisis team was in business continuity measures – meaning that many positions were left unfilled as the service struggled to cope with high demand.

The inquest was told that many calls from people in crisis were taken by unregistered and unqualified practitioners – with few of Linda’s calls to the team being picked up by registered mental health nurses.

Further evidence suggested that during some of these phone calls, Linda was told to calm herself down with hot drinks, even after she reported that she was experiencing suicidal thoughts that were “too much” for her to cope with.

Assistant coroner Janine Richards said the evidence suggested to her that Linda had been “passed from pillar to post” by healthcare agencies as she appealed for help.  In one instance, she said, Linda phoned the crisis team saying she wanted to cut her wrists. She was advised to phone her GP, who then told her to contact the crisis team.

The coroner heard from crisis team witness clinician Jayne Bennett, who had assessed Linda’s mental health needs at her home on two occasions. Ms Bennett thought that there was only “minimal risk” in Linda’s case and advised her to engage in coping mechanisms like “distraction” and to phone the crisis team again if she started to feel worse.

Though Ms Bennett believed that her assessments were comprehensive, she accepted that the case should have been escalated, and under new policy from TEWV, she would have referred Linda to the Early Intervention Psychosis Team following her paranoid and delusional behaviour.

Ms Bennett confirmed that unregistered and unqualified practitioners are still taking calls at the crisis team today, though the Trust has previously said that improvements have been made since the service came out of special measures.

Days after her final face-to-face assessment with Ms Bennett, police had to force entry to her Ferryhill home, after a family friend raised concerns.

Linda died the next day, with the cause of death found to be drug overdose and alcohol misuse following an autopsy. The inquest was told she had been rejected for treatment by the crisis team less than a week before her fatal overdose.

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An independent review noted that there had been a persistent “underestimation of risk” by Linda’s mental health team and that an “overall lack of awareness of team processes meant that her needs were not met”.

Nine weeks after Linda’s death, another crisis team patient David Stevens, took his own life. An inquest into his death noted that the crisis team “missed opportunities” in his care, though it could not be concluded that these significantly contributed to his death.

The inquest continues.