Frances Wellburn suicide: Inquest told of gaps in care

A former NHS manager who took her own life had received no formal mental health support for two months at the start of lockdown, an inquest heard.

Frances Wellburn, 56, from Fulford, York, was being treated for a depressive illness and was found hanging at her home on 2 August 2020.

An internal NHS trust report had found gaps in the care provided to her.

The coroner said it was “not possible to say whether they caused or contributed to her death”.

Giving a narrative conclusion, assistant coroner Jonathan Leach described Ms Wellburn as an “independent, intelligent and resourceful woman”.

He said she had received treatment for mental health issues for several years, but on 15 September 2019 she experienced a “sudden and unexpected deterioration” in her condition.

She was admitted to Cross Lane Hospital in Scarborough and was diagnosed with recurrent depressive disorder with psychotic symptoms.

After being discharged from hospital on 13 October 2019 Ms Wellburn’s care was provided by the community mental health team, but contact ended when the UK entered lockdown in March 2020.

Rebecca Wellburn
Ms Wellburn’s sister Rebecca said she hoped the trust recognised more could have been done to support her recovery

Speaking after the inquest, Ms Wellburn’s sister Rebecca said the “significant gaps” in care seemed to be essential to understanding the events which led to her death.

“I hope the Tees, Esk and Wear Valley [NHS Foundation Trust] recognise that more could have been done to support Frances’ recovery and prevent her tragic suicide,” she said.

The trust said it was “deeply sorry” for Ms Wellburn’s death.

Elizabeth Moody, director of nursing and governance, said: “We have worked hard to make improvements following our own review into Frances’s tragic death in 2020,” she said.

The inquest heard from Alison McGrath, the nurse who compiled the review into the care provided.

She highlighted no referral had been made to the early intervention in psychosis (EIP) programme, which she said should have been made “at the point the first episode of psychosis” was suspected.

However, she added it was “difficult to say” what difference it would have made.

Presentational grey line

The inquest heard Ms Wellburn’s health deteriorated and she was detained under the Mental Health Act after taking an overdose on 26 May.

She remained in hospital until 25 June and was once again cared for by the community mental health team throughout July.

She last spoke with her care coordinator on 27 July and her consultant psychiatrist on the 28 July.

The coroner said they had agreed there was no need to “escalate” her care and that an assessment under the Mental Health Act was not required.

On 2 August, police responded to a call from her family who were concerned.

North Yorkshire Police attended her home on Main Street in Fulford and found her body.