A North East mental health trust has been criticised by the coroner following the death of a 48-year-old woman, who contacted the crisis team multiple times in the days preceding her death. 

Linda Banks, from Ferryhill, died in April 2022 after taking an overdose. She had a long history of self-harm and suicidal thoughts, as well as struggles with alcohol misuse and learning difficulties that compounded her vulnerability. 

Now, Ms Janine Richards, assistant coroner for Durham and Darlington, has criticised TEWV in a Prevention of Future Deaths report. She has outlined concerns about the trust's delays in the successful implementation of improvement plans and reports that are filed months late.

At the time of her death, Linda was a patient at the trouble-hit Tees, Esk and Wear Valleys (TEWV) crisis team. Linda herself, her family and her friends, made multiple contacts with mental health services between February 2022 and her death, as her mental health deteriorated.

The Northern Echo: Linda Banks died in 2022.

The inquest heard that though concerns were expressed as to her safety repeatedly, she was labelled "low-risk" by the crisis team, and her family were advised to use a "tough love" approach.

Though counsel for TEWV said this "simply did not happen", coroner Ms Richards said she was “entirely satisfied” that although exact details may be mistaken the general advice to step away was given. She branded it “wholly inappropriate”.

In her Prevention of Future Deaths report,  the coroner writes that the implementation of planned improvements following several other tragic deaths related to the crisis team was still a "work in progress" when Linda's mental health took a turn. 

The coroner also outlines that TEWV failed to file a Serious Incident report looking into circumstances surrounding Linda's death, until nine months afterwards.

The inquest heard that this is well beyond the 60-day timeframe set out in NHS guidance.

Ms Richards labelled this "neither timely nor responsive", and outlined that "despite reassurances given that the Trust are working to eradicate such delays there are still cases coming to the attention of the Coronial service where Serious Incident Investigations are significantly delayed in excess of the 60 day NHS framework."

The trust maintains it continues to learn lessons and has made significant improvements. 

The crisis team came out of continuity measures in June 2023. TEWV adopted new processes including a 24/7 listening service, peer workers undertaking home visits, and “happiness hubs” to support wellbeing.

But Linda's family have said that this has provided "absolutely no comfort", with her brother Jonathan adding that the crisis team, which was heavily involved in Linda's care, "should never have been allowed to reach those depths."

Linda's death was preceded by those of four other crisis team patients in early 2021, which prompted a thematic review of the service. This identified several significant issues with the care they offered.  

Seven of the eight issues identified by the crisis team thematic review were still found to be issues in Linda's care - meaning that the trust has known about issues facing the crisis team since November 2021, four months before Linda's death.

Concluding the inquest, the coroner said: "Any actions taken as a result of the thematic review were not effective in implementing change and that the action plan was still a 'work in progress' at the Pre Hearing Review Hearings which took place in this case in 2023."

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Jonathan Banks, Linda's younger brother, said: "Yet again the failings of the Durham and Darlington Crisis Team have been highlighted in the tragic death of my sister, Linda.

"A catalogue of errors was revealed by the much-delayed review into her death which was after a thematic review following 4 earlier deaths and many of the serious issues from that earlier review remained at the time of Linda’s death.

"It is absolutely no comfort to say the crisis team was no longer in special measures, it should never have been allowed to reach those depths and contributed to Linda’s tragic death."

Beverley Murphy, chief nurse at the trust, said: “Coroner hearings can be very difficult for a family, and Linda’s family have been in our thoughts throughout. We are truly sorry for their loss.

“We reviewed Linda’s care and listened closely to the concerns of her family. We identified areas to improve and have been working hard to make these changes.

“We will act on the inquest findings and remain committed to these improvements and providing the best care possible.”