Mother says the system is broken after 23-year-old daughter’s inquest
PUBLISHED: 16:50 12 March 2019 | UPDATED: 17:19 12 March 2019
A 23-year-old woman with a depressive disorder grew dissatisfied with the care she was receiving before she was found dead at home, a court was told.
Her mother said the system was broken, because too many people were involved in her care.
Tamsin Grundy was found unconscious in the bedroom of her home at Ryston Road, Denver, near Downham Market on July 26, 2018.
An inquest in King’s Lynn today heard she was pronounced dead at the scene. A post mortem later gave the cause of death as compression of the neck.
Norfolk senior coroner Jacqueline Lake heard Miss Grundy had began suffering anxiety in 2014, after starting a modern languages course at Birmingham University.
In 2016 she dropped out of college and returned home to Denver, where she was referred to mental health services for treatment.
Mental health practitioner Conrad Brown said in a statement Miss Grundy expressed suicidal thoughts on a number of occasions.
He said she told him: “I feel like I have so many appointments with so many people without moving forwards.”
Miss Grundy made a number of attempts to take her own life, the coroner heard.
In a statement her GP, Dr Chris Holmes, said she had a “disjointed and unsatisfactory interaction” with mental health services.
On January 17, 2018, Miss Grundy was admitted to the Fermoy Unit at the Queen Elizabeth Hospital after taking an overdose.
She told a senior mental health nurse she was fed up with the NHS and mental health because they offered “no clarity or continuity of care”.
Miss Grundy was assigned a new care coordinator after Mr Brown changed jobs. Clinical Psychologist Dr Miles Lattimer said her case was discussed at a number of team meetings.
He said one was called to discuss her unwillingness to engage with services or her new coordinator.
Between November 2017 and January 2018, Miss Grundy began CBT (cognitive behaviour therapy) with Dr Phil Hayes. The coroner heard she had a number of sessions before January 2018, when Dr Hayes had a heart attack.
The court heard another therapist was not available to continue her treatment. But there were concerns over whether CBT was working, or whether it was triggering emotional problems.
Practitioners wanted Miss Grundy to engage with them to stabilise her condition before allowing it to continue.
Rev Grundy said her daughter believed she could be cured if she was given further CBT. She said she felt she had “given up”.
The court earlier heard she been involved with four different mental health teams. Her mother asked why so many people had to be involved.
Mrs Lake concluded that her death was suicide. She said she was concerned at the number of people involved in her care and would be writing a report to the trust.
Solicitor Maeve Sykes, for the Norfolk and Suffolk Foundation Trust, said its teams were based on a national care model and staff were needed to operate a 24/7 service.
After the hearing, Rev Grundy said: “The system is really broken, there are too many people involved. I will miss her all my life.”
Stuart Richardson, chief operating officer at the health trust, said: “I am so sorry to hear about the tragic death of Miss Grundy and would like to offer my sincere condolences to her family and friends.
“We accept the findings made by the coroner today and will work with our commissioning partners to make every effort to reduce the number of different care professionals a service user sees when under the care of the crisis resolution and home treatment team.
“We are getting in touch with the family again and I hope to be able to meet with them soon to discuss this further.”
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