Mother astonished by agency’s ‘failures’ before daughter’s death

The mother of a woman who killed herself by ingesting a toxic substance purchased online has criticised “failures and misunderstandings” in her daughter’s care.

Beth Langton, 22, who had been diagnosed with a personality disorder and complex post-traumatic stress disorder, was discovered in her flat in Retford, Nottinghamshire, on February 18, 2023.

An inquest heard his death followed a “significant reduction” in the support he was offered, which meant his mental state was “adversely affected”.

Ms Langton’s mother, Shelley Macpherson, said the investigation had uncovered failings “worse” than she had imagined.

Ms Macpherson told the BBC her daughter’s mental health problems began when she was a teenager and she was admitted to a residential care facility when she was 17.

She said Ms Langton received ongoing care, lived outside the family home and eventually moved to a flat at Oakwell House – a residential home for women with mental health problems.

“When she first arrived at Oakwell House she had 24/7 support from staff as well as support from the community mental health team,” Ms Macpherson said.

“But in 2022 the NHS Trust (Nottinghamshire Healthcare NHS Foundation Trust) released her saying she had enough support in the community.”

She added that neither she nor her daughter were comfortable with the change, especially given the medication Ms Langton was prescribed.

As an adult, Ms Langton had to give her mother permission to intervene in her care.

Mrs Macpherson, 48, said: “We had a difficult Christmas that year. From that point on, until she died, she was not in a good place. She was disconnected from everything.”

She said that in the run-up to her daughter’s death, Ms Langton had made an appointment with the council-appointed social worker and asked for all her “observation hours” at Oakwell House to be removed. This meant staff had no obligation to spend one-on-one time with her.

Ms Macpherson said: “We were shocked that the social worker agreed to this without consulting anyone else.”

The day before Mrs. Langton died, she called her mother, as they usually did on days when they did not see each other in person.

“She actually seemed more positive. She asked me if I was angry with her and I said, ‘No, of course not, I love you,'” Macpherson said.

“In hindsight, it makes sense now.”

The next day, Ms Macpherson was waiting for her daughter’s call when two police officers knocked on her door to tell her she had died.

Ms Macpherson said her daughter had said she wanted to be “normal like everyone else”.

“Beth was very creative, she had a real talent for writing poetry and she used it a lot to deal with her emotions. We have a lot of her poems now,” she said.

“As a child, she was a carefree little girl. She loved to do things, especially if it was something she could win at. She tried everything.”

An inquest at Nottingham Coroners Court into Ms Langton’s death concluded last month.

It was understood she had obtained the substance online, which she “deliberately ingested with the intention of causing her death”.

Coroner Laurinda Bower found that decisions to reduce support for Ms Langton “were often made in isolation and based on inaccurate information about the support Beth was receiving”.

In her recorded findings, Ms Bower said: “The withdrawal of support led to feelings of abandonment and rejection linked to Beth’s personality disorder.

“These feelings of abandonment and rejection were one of the many issues that negatively affected his mental state as he approached his suicide.”

The coroner then issued a report aimed at preventing future deaths to various agencies.

In the report, she said: “Beth used the internet to research how to obtain and use (the substance) to cause her death. She followed that advice to the letter. That same advice was still readily available on the internet at the time of her investigation, although I believe it may have been removed now.

“What system is in place to ensure that such websites are detected quickly and made inaccessible to the public as soon as possible?”

Law firm Leigh Day, which represented Ms Langton’s family at their inquest, said it had received advice from Gillian Merrill, a clinical psychologist engaged by Oakwell House.

The firm said Oakwell and Ms Merrill did not have a written contract or terms of reference for her role or the support she would provide to Ms Langton.

Leigh Day said the “fluid” arrangement had “created significant misunderstandings between the agencies involved in Beth’s care”.

This includes, the report said, concerns raised in spring 2022 about Ms Langton’s exit from Nottinghamshire Healthcare NHS Foundation Trust “for the first time in more than a decade”.

“The coroner heard evidence that the decision was made largely as a result of a misunderstanding of Ms Merrill’s role and the psychological services she provided to Beth,” the firm said.

“Beth herself informed the mental health team at the time that she was not receiving the support she thought she would receive, which, as her care coordinator admitted at the inquest, should have led to a review of her release.”

Ms Macpherson said the evidence presented at the inquest, which closed on July 8, was “staggering”.

“It was extremely distressing,” she said.

“We thought we knew there were missteps and missed opportunities, but it was much worse than we had imagined.

“All I ask is that things improve so that this doesn’t happen again.”

If you have been affected by any of the issues raised in this article, you can visit the BBC Action Line.

Creative Care, which runs Oakwell House, said that while Ms Merrill was self-employed and provided a “drop-in service for staff and residents”, the psychologist “was not intended to replace any prescribed care programme”.

“The decision on the level of support received by service users in the form of a care package is determined by health and social care professionals and not by Creative Care.

“We are aware of the coroner’s concerns about a misunderstanding of services which led to a disjointed delivery of care, and steps have been taken to improve inter-agency communications,” a spokesperson added.

Dr Susan Elcock, executive medical director and deputy chief executive of Nottinghamshire Healthcare NHS Foundation Trust, said: “We are working with our partner agencies to address the issues raised by the coroner and improve the experience of care for our current and future patients.”

Melanie Williams, Executive Director of Adult Health and Social Care at Nottinghamshire County Council, added: “Nottinghamshire County Council conducts regular reviews of its practices and the support it provides and will always make any improvements that may be necessary.”