AN INVESTIGATION into the care delivery of an NHS trust has identified several 'problems' with its service following the death of a Barrow mum wh had been in its care.

Karen Kelsall, 53, was found unresponsive in her car in Barrow by her husband Andrew on October 23, 2020.

READ MORE: 'Missed opportunities' - death of 'fierce and proud mother' triggers NHS Trust investigation

An inquest carried out at Cockermouth Coroner's Court heard Mrs Kelsall had struggled with anxiety and depression over the last 18 months of her life. She was placed in the care of Lancashire and South Cumbria NHS Foundation Trust (LSCFT) mental health services after thoughts of and attempts at suicide but was discharged in January 2020.

A Serious Incident Requiring Investigation (SIRI) report was compiled prior to the inquest to determine whether the trust's actions had contributed to Mrs Kelsall's death.

Rachel Warwick, a service manager from LSCFT, attended the inquest and was questioned by Area Coroner for Cumbria Ms Kirsty Gomersall about the report, of which Miss Warwick was not the author.

Ms Gomersall said in her summary of the evidence given: "Miss Warwick was keen to express that she did not think that Karen's family could have done any more in relation to her support, and also outlined that in her view the trust had done what it could in terms of care and treatment, and at the point of discharge from the services, Karen's risk was manageable."

Three 'care and service delivery problems' had been identified by the report:

  • there are differing perspectives of the level of risk across the mental health services
  • her GP was not sent a letter following Mrs Kelsall's discharge in January 2020 so that they could monitor her reaction to her medication.
  • Mrs Kelsall was not informed that she had been discharged and no rationale was given.

Miss Warwick outlined action that the Trust has since taken including a more 'person-centred' risk assessment tool has been adopted, extra secretarial staff have been employed, extra training given to the team, adoption of an intervention-based model of care, weekly meetings, access to a psychologist, and a 'triangle of care' assessment.

Ms Gomersall concluded: "I do not consider it would be safe for me to say that on the balance of probabilities, (the issues identified) were materially contributive towards Karen's death. 

"That does not take away from the fact that the trust has outlined the care and service delivery issues."