Samantha Metcalfe death: Welfare check took 15 hours

Samantha Metcalfe, 51, known as Sam to her friends and family, died on September 26, 2022, in her Guisborough home.

An inquest at Teesside Coroner’s Court heard that 15 hours had elapsed between healthcare professionals raising concerns for Sam, and police officers finding her dead whilst performing a welfare check.

Sam, who was originally from Teesville, had been diagnosed with emotionally unstable personality disorder. Her consultant psychiatrist, Dr Peter Cornwall, told the court that this meant she had “high levels of anxiety, low self-worth, periods of self-harm, and had trouble forming close attachments and relationships”.

Sam had phoned the crisis team at around 6.30am. The team, which offers urgent support and care to adults who are experiencing a mental health crisis, is run by Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV).

Records made by the call handler indicate that during the half-hour-long call, Sam expressed thoughts of harming herself, but said she had no thoughts of taking her own life. A meeting with her support worker, scheduled for later that morning, was mentioned.

But when her support worker went round to her flat, the inquest heard that Sam did not open the door, and did not pick up any phone calls, or respond to text messages.

This was deemed “unusual” and “out of character”, especially as the support worker could hear Sam’s beloved dog Truly, whom she would never usually leave alone, barking from inside the property.

She escalated her concerns about Sam’s welfare at Foxrush House, a TEWV centre in Redcar dealing with early mental health interventions.

Even though Sam’s support worker had raised concerns at 11.30am on September 26, the inquest heard that a decision by medical professionals to give Sam time to respond to their phone calls, and a “lack of resources” at Cleveland Police, meant that no one attended her property until 4am on September 27.

She was found in her bedroom hours after her support worker initially raised concerns.

Sam’s family have raised concerns about “the number of red flags” she presented that morning, saying “she was crying out for help”.

Speaking to The Northern Echo, sister Christine Metcalfe, 49, said: “To us, it’s just so obvious that she wanted someone to come speak to her. [After Sam’s death] we found a bag she had packed by the door, with underwear, pyjamas, slippers, deodorant and magazines from that week.

“That is clearly a bag for hospital. She was expecting to be sectioned, and she wanted someone to care. Sam hadn’t locked the door, only put the bar across – she wanted to be found, but thought that no one was coming.”

The trust has said that there were “learning opportunities” to draw following Sam’s care. Jane O’Neil, the director of nursing quality at TEWV, told the inquest that the Trust acknowledged that Sam’s family “should have been informed at the point that the police were becoming involved.”

She also noted that “we would have expected an out-of-hours service would have continued the conversation [about Sam’s welfare] with police.”

But a report into the incident by Cleveland Police said at the time of the initial call from TEWV, there were “no free resources for immediate dispatch”, and the Trust did not follow up on Sam’s case after 5pm, when shifts ended.

Over the rest of the afternoon, and into the night, police explained- “a number of high-demand and high priority incidents, where there was threat to life, meant that dispatching units was not possible due to a lack of resources”.

Sam’s younger sister Christine, said she feels “let down” by the trust.

Despite her troubles, Christine remembers her beloved and “fun-loving” older sister as someone “who would have done anything for you”.

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She said: “She was an avid Hercule Poirot and Miss Marple fan, she could recite any of them off by heart to you. She was a big fan of the royals and was devastated by the queen’s death. We cremated her in her jubilee dress, which was the colour of the Union Jack.

“Sam was one of my main carers after I was in a serious accident, if you ask anyone who knew her, they’ll tell you she’d have done anything for you. She loved her pets, and would love a walk down on the beach.”

Though the coroner said different circumstances in the run-up to Sam’s death “might not have made a difference if Sam’s family were contacted, but it needs to be borne in mind. Family is always a valuable resource”.

Assistant coroner Karin Welsh ruled that Sam died of “an excess of medication”.