'Loving' woman found dead at home
PUBLISHED: 08:00 15 July 2015
The appropriate precautions were not taken to stop a 29-year-old Nailsea woman from hanging herself, a coroner has concluded.
Natalie Clarke, from Westway, had been under the care of Avon and Wiltshire Mental Health Partnership NHS Trust (AWP) following an overdose in 2006.
At an inquest into her death at Flax Bourton Coroner’s Court on Friday, the court heard Natalie suffered from anxiety and depression and struggled with issues of grief and loss.
Natalie was found hanged in her garage on July 31 last year, following two unsuccessful suicide attempts in the days before her death.
Speaking after the inquest her family said: “Natalie was a loving and caring daughter and sister who had many achievements for someone so young.
“She worked hard to overcome her illness and overall we’re thankful for the care from the NHS.”
Natalie had been receiving treatment from the trust’s recovery team, based at the Coast Resource Centre in Weston.
The court was told Natalie began calling and visiting the team almost daily throughout July as she was having suicidal thoughts.
Sarah Gregson, a social worker with the team, said Natalie called the office on July 21 requesting hospital admission as she was ‘feeling suicidal’.
Due to her increasing level of risk, Miss Gregson contacted the intensive support (IS) team, based at Long Fox Unit in Weston, to request a visit to assess for voluntary hospital admission.
Following the assessment, both teams decided to continue treating her at home.
Miss Gregson said: “Natalie was willing to give the intensive support team a go at home. I did think that an admission to Juniper ward (at the Long Fox Unit) may have been more damaging.
“Home treatment was preferable because it’s less restrictive.”
Natalie tried to hang herself on July 28 and 30 but was still not admitted to hospital as she was ‘future focused’ and ‘willing to engage the intensive support team’.
She was visited by mental health worker Hannah Bush who said: “Natalie broke down in tears and said she’d tried to hang herself.
“She’d found herself passed out on the floor and called the IS team.
“I arranged a visit for the next day. I felt Natalie was safe to leave that evening. I had suggested hospital admission to her but she was ambivalent.”
Members of the team were due to visit Natalie at 4pm the next day, but due to an emergency call they arrived at 5pm to find Natalie hanged in the garage.
A note which read ‘I’m sorry, no-one is to blame’ was found in her kitchen.
Assistant coroner Simon Fox recorded a narrative conclusion. He said: “Miss Clarke took her own life in part because appropriate precautions were not taken to prevent her doing so.”
Emmy Watts, access services manager for AWP confirmed a number of changes have now been made as a result of Natalie’s death.
The team has hired a shift co-ordinator to ensure records are updated, every patient at risk of suicide is visited by a band six member of staff and risk reviews are also carried out twice a week.