Family of tragic Norwich mother call for NHS crisis change

Maggie Harvey was found dead in her Norwich home hours after calling an NHS crisis line because she was fearing for her own safety.

During an inquest into her death, the court heard her mental health care was rife with miscommunication, confusion and delays after she had moved from Suffolk to Norfolk - despite services in the two counties being run by the same organisation.

It heard Mrs Harvey, who was 67, had left the Bury St Edmunds community mental health team of the Norfolk and Suffolk NHS Foundation Trust (NSFT) and had initially been reluctant to accept care of the Norwich team.

With her agreement, Mrs Harvey was discharged but given directions on how to reaccess care if she needed it.

However, after making efforts to reaccess care a miscommunication saw her new referral refused.

The blunder came after officials at NSFT mistook the referral as coming from a GP - rather than from the trust's own mental health nurse based at the surgery.

The refusal letter, sent on March 10 last year, instead recommended she should see the very same mental health nurse that had referred her.

Area coroner Samantha Goward said it should have been made clearer that the initial referral was made by a mental health nurse and not a GP.

Evidence was heard that this knowledge may have resulted in the referral being accepted - but that Mrs Harvey may still have faced a 28 day wait to be seen.

AMBULANCE DELAYS

Three days after the letter was sent, at 9.58pm, Mrs Harvey phoned 111 option 2 - an NHS crisis line which is run by NSFT.

During the call, which lasted 48 minutes, she told a crisis care practitioner that she did not feel could keep herself safe.

The call handler told her a referral could be made to the NSFT's crisis team, which aims to reach people within four hours.

Mrs Harvey, however, declined this as she did believed she could keep herself safe for this length of time.

After the call ended, the handler immediately phoned 999 to arrange for an ambulance to attend her home in Newmarket Road.

However, he was told that due to service pressure at the time she would not receive a callback for six hours - and that it would take 12 hours for an ambulance to attend.

Christopher Hewitson, patient safety officer at the East of England Ambulance Service Trust, said the call was also incorrectly given the lowest priority - category five.

At 12.56am, a clinician from the ambulance trust attempted to contact her but could not reach her, resulting in her call being escalated.

But it was not until 3.38am on March 14 that paramedics reached her home and found her unresponsive.

'GAP IN SERVICES'

Mrs Goward said the case had raised concerns about how mental health emergencies are handled.

She said: "There are a few areas of concern and it feels to me that there is a gap in services.

"My concerns are in terms of mental health patients and their needs if there are not emergency services available.

"If there is a risk to their safety they do not have a specific emergency service - and who fills that gap."

Evidence was heard from both NSFT and EEAST that work is ongoing to address this issue, including a specific rapid response vehicle for mental health patients.

However, this is a limited service and only runs from 1pm until 1am.

Mrs Goward gave a narrative conclusion that Mrs Harvey had taken a deliberate action to end her own life during a mental health crisis she was seeking help for.

She added that she was considering writing a report to prevent future deaths - which was dependent on further evidence being submitted by both NHS trusts.

​FAMILY TRIBUTE

In a statement issued following the inquest, her four children - Liz, Will, Ed and James said: "Maggie Harvey was a beloved mother and grandmother to her six young grandchildren.

"She was a passionate mother and grandmother, her family were the most important thing in the world to her.

"She was also an incredible friend, always there in times of need and always there to put smiles on people's faces.

"She had a huge network of friends who were there for her through the good and bad times.

"She had an infectious laugh and the ability to touch people's lives more than she ever realised.

"Despite her challenges mentally and physically, she was a fun-loving, outgoing lady who showed incredible resilience, strength and bravery.

"She is hugely missed.

"We as a family would like to thank the coroner for highlighting the issues that contributed to her death and we hope to see changes in how mental health emergencies are dealt with in the future."

ANALYSIS

Maggie Harvey's case is a heartbreaking one to report - but one that is incredibly important.

The tragedy highlights the fractured nature of mental health services, particularly in our region and raises a number of pertinent questions.

While it is important to point out these things are very easy to say with the benefit of hindsight, it certainly appears to be the case of a woman who desperately wanted help - but could not get it.

This is why it is vitally important that lessons can be learned from her case.

Perhaps the most pertinent matter arising from the inquest though is the need for clarity over the emergency response to people in mental health crisis - an issue that has been hugely topical in the light of last month's killings in Costessey and the decision by the police to pause its 'Right Care Right Person' policy.

During the hearing, it was emphasised how difficult it can be to assess the urgency of mental health crises.

It is true to say that psychological trauma does manifest itself differently from physical and the latter is clearly more straightforward to spot accurately.

And therein lies a huge part of the issue with a system in which mental and physical have to compete against one another for priority.

This is what makes the coroner's comments on there being a need for specific emergency response provisions for mental health crises.

Cases like Mrs Harvey's tragically emphasise that while there continues to be ambiguity over just who responds to these people in their urgent moment of need, people will continue to die.

It also emphasises key issues still facing the region's struggling mental health trust in terms of how it not only communicates with partner organisations - but different parts of itself.

On the surface, mental health nurses being accessible to GP surgeries is a fantastic idea and indicative of efforts to make primary and specialist care work closer together.

And this is absolutely vital across all health services, from hospitals to GPs, to mental health trusts, to social care.

But, sadly, until these organisations start singing from the same hymn sheets, confidence in services will remain low.