Mum says mental health team has ‘blood on its hands’ on anniversary of daughter’s death

A grieving mother is backing calls for a statutory public inquiry into Essex’s mental health services on the anniversary of her 21-year-old daughter’s death.

Lisa Bates is part of a growing number of bereaved families refusing to engage with an independent investigation announced by the Government.

She says it won’t go far enough to address a catalogue of failures leading to the deaths of around 30 people, claiming parents will only see justice through a full statutory inquiry – which requires people to give evidence under oath.

Today Lisa, 54, from Brentwood, marked the one year anniversary of her daughter Tillie-Anne King’s death, and still doesn’t feel she’s had the closure she deserves.

On March 8, 2020, she found Tillie pale and unresponsive, lying on her bed after taking a fatal dose of anti-depressants, mood stabilisers and alcohol.

Two weeks later, she was sent a letter from the Essex Partnership University NHS Foundation Trust to arrange a review of her medication, despite her mother telling practitioners she had already passed away.

A coroner ruled Tillie’s death as being drink and drug related and it is not thought she intentionally took her own life, rather her anorexia and bulimia had left her so underweight her body couldn’t process what she had taken.

Lisa says her daughter was referred to Cassel Hospital, south-west London, for treatment for her eating disorders, but as professionals in Essex hadn’t first addressed her drinking problem, she was turned down.

She told ‘With Tillie being let down like that, she’s losing her faith in the people who are meant to be looking after her.’

Lisa says her daughter first became involved with Child and Adolescent Mental Health Services (CAMHS) when she was 13 – struggling with bullies at school and her mum and dad separating.

She ended up dropping out of mainstream education and self-harming, which got progressively worse to the point where she ended up in hospital.

Lisa said: ‘They came and gave her a mental health assessment and they said that she was well enough to go home but I refused to take her home because I couldn’t keep her safe because she was cutting.

‘I went on a course for families of children who self-harm and in that course I learnt that no matter how hard I tried to keep Tillie safe at home, she would always find a way to harm herself.

‘It was very hard for us as a family to take on board why she is doing this to herself.

‘When she was underage, as long as I could kick up enough stink, she was fine, I could keep her safe.

‘When the transition from CAMHS to adult health services happened, it was awful, she was full of anxiety and she really struggled.

‘She found it really hard to trust people. You just don’t have the continuity with the same staff all the time, you don’t see the same staff all the time. Every time Tilly would go she would have to re-tell her story.’

By the time Tillie was 18 had turned to alcohol and Xanax – a powerful tranquilliser – to cope with how she was feeling. On one occasion this led to her ending up in intensive care and in an induced coma, with no sign of whether she would wake up.

Lisa said: ‘It was a total of three days, she was assessed, went home with a week’s worth of tablets. Then three weeks later she was back in intensive care, back on life support and was released again, three days later, because she knew what to say and she knew how to say it.

‘I was her main carer, I voiced my concerns, I said how worried I was and nobody listened. ‘They give you a crisis phone number to call, but as long as your crisis is between nine o’clock in the morning and five o’clock in the afternoon Monday to Friday you might get someone answer the phone.

Why give somebody a number for a hotline when they have got phone phobias?’

By this point, Lisa says her daughter had been given nine different diagnoses, including bulimia, anorexia, borderline personality disorder, anxiety and depression.

She believes Tillie began to self medicate because practitioners weren’t ‘dealing with the root cause of her problems’.

‘In fact her care coordinator did sit in my front room and say “I don’t know what to do with you Tillie”, and then accused her of “disengaging”, which is quite a surprise really, “what 20 year old will want to engage with somebody who’s meant to be looking after them when they tell them they don’t know what to do with them?”, Lisa said.

She added: ‘It was hard work getting her to appointments. Her appointments were nine times out of 10 in the morning, and they knew Tillie’s sleep pattern was diabolical and she would be in bed all day. ‘Some days she found it hard to attend the appointments, which was taken as a negative, they didn’t try and sort out the situation.’

Lisa also believes her daughter also used drugs and alcohol as a coping mechanism after a man she met online sexually abused her in August 2019.

She says four referrals were made by her care coordinator but none of them were followed through, and Lisa still ‘can’t get to the bottom’ of why.

It was only after Tillie’s death that Lisa was told she could have made a referral on her daughter’s behalf.

Lisa says Tillie was finally offered help for her alcohol misuse in January 2020, just months before she died.

She claims there were 151 errors in a serious incident report written up by the Essex Partnership University NHS Foundation Trust.

Despite being told these would be amended ahead of the inquest in September, she says this was never done in time.

Lisa added: ‘I had to wait until the day before the inquest to find out that the new report wasn’t ready. I then had to go to my daughter’s inquest knowing that they were going to use the wrong report.

‘I then had to sit and watch the author of the report fumble her way through a report that she knew was wrong, the main coroner knew was wrong and we knew was wrong.

‘They said that mine and Tillie’s relationship was toxic, which was far from it, we were best friends and she was my soulmate.

‘I understood her illness and she understood me, to write that it was toxic was so, so, heartbreaking because it was far from the truth.
The coroner sat and asked the mental health representatives, “does anyone actually read these reports?
Does anyone really get training from these findings?
The mental health worker didn’t answer.’

Lisa is now joining a campaign led by Melanie Leahy, whose 20-year-old son Matthew was found hanged at the Linden Centre in Chelmsford in 2012. He was one of at least seven to die at the site since 2001 and his mother is still demanding answers.

Some 66 families have written to mental health minister Nadine Dorries calling for what would be the country’s first ever mental health statutory public inquiry.

Lisa added: ‘We hand our loved ones over to these people to look after them. These people are meant to know what’s best for our loved ones, yet they don’t communicate with us, and we’re their carers.

They don’t take on board what the carers are saying, and these people need to be accountable.

‘In my eyes, these people that have let her down have got blood on their hands.’

That is why I am backing Melanie Leahy for the statutory public inquiry because these people need to be held accountable.’

A Department for Health and Social Care spokesperson said: ‘Every death is a tragedy. We have launched an independent inquiry into inpatient mental health deaths across the whole of Essex between 2000 and 2020. ‘Dr Geraldine Strathdee CBE took up the role as chair of the independent inquiry in January and we expect the inquiry to be formally established from April 2021 and the Chair will consult with the families on the full terms of reference. ‘It is vitally important we learn from these events in order to benefit care across the wider NHS and protect patients in the future.’

Credit James Hockaday

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