The inquest into death of Deborah Patricia Hayes has identified failings by a telephone service operated by West London Mental Health NHS Trust.

Deborah Patricia Hayes, aged 62 and living alone, was found dead at her home on 23 December 2023.

Two days earlier on 21 December 2023, Metropolitan police officers and paramedics from the London Ambulance Service were called to Deborah’s home after she confided in a friend that she had ingested a toxic substance leading to emergency services being called. Deborah’s friend informed the police that Deborah was at her home address at the time of the suicide attempt.

Deborah refused to attend hospital but with the assistance of paramedics, Deborah spoke with the telephone-based Single Point of Access Service (operated by West London Mental Health NHS Trust).

A toxicology report confirmed that Deborah had died after ingesting a toxic substance. Deborah had a history of this pattern of self-harming behaviour.

Deborah was also known to mental health services due to her diagnoses of emotionally unstable personality disorder, agoraphobia and body dysmorphic disorder.

On Friday 27 June, the inquest jury concluded that the risk category attributed to Deborah by the Single Point of Access Service probably contributed to her death due to a failure to follow their own procedures when assessing her.

Basmah Sahib, Solicitor in our Public Law team, said

Deborah is warmly remembered by her friends and family as an ardent cyclist who had a knack for DIY projects and a keen eye for fashion. Her brothers sat in court alongside Deborah’s friends and relatives, all of whom miss her dearly.

Deborah’s loved ones are grateful to the coroner for the broad focus of this inquiry, which was the full and fearless investigation that Deborah’s family had hoped for. They are also grateful to the 11 jurors for their careful deliberations and helpful findings, which they feel reflect the failings in Deborah’s case.

The family heard about changes to the Single Point of Access Service implemented by West London NHS Trust following Deborah’s death. They welcome the coroner’s remarks that Deborah’s sad death has enabled the system to become a lot safer and hopefully prevent other families having the grief and loss experienced by them.

Background to the Case

Single Point of Access is a telephone service operated by West London Mental Health NHS Trust. It is intended to streamline access to community mental health services and triages referrals from all sources including police and ambulance services.

During the afternoon of 21 December 2023, Deborah ingested a toxic substance with the intention of ending her life. Deborah’s friend alerted the police, who immediately attended Deborah’s home.

Deborah admitted to the police officers that she had ingested a toxic substance but declined to go to the hospital to receive life-saving treatment. Because of the medical nature of the emergency, an ambulance had also been called but took over an hour to attend.

While waiting for paramedics, the police officers attempted to seek guidance from mental health specialists by telephoning the Single Point of Access service. There was no answer, despite a long wait on hold.

When paramedics arrived, Deborah again declined to attend hospital. They, too, telephoned the Single Point of Access service for advice.

This time, Single Point of Access answered. The paramedics were under the impression that they were speaking to a clinician, though it subsequently came to light that they were speaking to a Health Care Assistant who – per West London NHS Trust’s operational policy – was not permitted to triage calls.

Despite this policy requirement, the call handler proceeded to complete a triage form discussing information obtained on the call at times with a senior clinician (who was a mental health nurse).

The outcome of that call was that Deborah would remain at home for an undefined period awaiting face-to-face assessment by the community mental health team. This was on the basis that Deborah’s risk level had been deemed as ‘non-urgent’. Other urgent referral options were available including response times of 4 to 24 hours for a face-to-face assessment, but these options were not considered necessary at the time.

Deborah was found dead around 48 hours later.

NOTES

Deborah’s family are represented by Basmah Sahib of Bindmans and Counsel Rachel Woodward from Doughty Street Chambers, who have published a press release here.

Deborah’s family were granted Exceptional Case Funding by the Legal Aid Agency for representation at Deborah’s inquest. Other Interested Persons at the inquest included West London Mental Health NHS Foundation Trust, the London Ambulance Service NHS Trust and the Metropolitan Police Service.

Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.