Advising with empathy and experience

Vulnerable woman's tragic death.

The parents of a vulnerable woman who died while under the care of mental health services in Plymouth are to meet a senior police officer to discuss the circumstances surrounding their daughter's "avoidable" death.

Ruth Mitchell, 40, a diagnosed schizophrenic, was found dead in her flat in September 2012, prompting a series of critical enquiries and reports which highlighted failings in her care.

In November 2017, a Safeguarding Adults Review by Plymouth Safeguarding Adults Board published 11 findings and made 12 recommendations for future practice as a result of her case.

The Safeguarding Adults Review highlighted several missed opportunities to respond to concerns about her deteriorating condition, including the failure to implement vulnerable adults safeguarding procedures or to raise her level of care when it was clear she was self-neglecting.

Following the report’s publication, Ruth Mitchell’s parents, Russell and Anne Mitchell, said there was a case for corporate manslaughter and asked Devon and Cornwall Police to investigate.

They also called for a second inquest to be held so that all the information that has come to light since Ms Mitchell’s inquest in July 2013 could be considered.

Devon and Cornwall Police said it has now assigned a senior officer to meet with the Mitchells to discuss the case.

Mr and Mrs Mitchell said the way their daughter’s care plan was managed led to her “avoidable death” in “total reclusiveness.”

Mr Mitchell said: “We see it as a natural next step arising from the independent inquiries conducted so far, which, whilst examining why things went so tragically wrong for Ruth, did not address culpability."

Ruth Mitchell was underweight, 7st 8oz, at the time of her death and there was no flooring, furniture, food, cooker, bed or mattress in her flat. She had been sleeping on the floor and there had been no hot water or heating for more than four years.

The report published by Plymouth Safeguarding Adults Board also highlighted failures to carry out any capacity assessment on Ruth Mitchell and failures to flag up her condition and vulnerability with other agencies such as the police and housing.

At the initial inquest into the death in 2013, the toxicology report showed “potentially fatal ketoacidosis”, a condition that can be caused by starvation. The cause of death was bronchopneumonia and pulmonary embolism.

In a narrative verdict, Plymouth coroner Ian Arrow said that Ruth Mitchell had self-neglected, but added: “She was malnourished, and, on the balance of probability, had previously consumed significant quantities of alcohol.”

Police dealt with three incidents with Ruth Mitchell in the first half of 2007. In June, her parents made a complaint to health services and asked for the level of care to be enhanced and more focused.

However, following a review, mental health services reportedly decided to discharge her from the Enhanced Care Plan and put her down to standard care despite concerns from her consultant psychiatrist, a decision her parents describe as “perverse”, saying it led to her increasing isolation, self-neglect and eventual death.

Ms Mitchell was supposed to attend three-monthly outpatients’ appointments with a consultant psychiatrist and a mental health nurse, who would update her parents about her attendance.

However, the nurse was able to attend only four out of 14 scheduled meetings before moving to a new health team in 2009 and no arrangements were made for another health professional to take over her role.

The community psychiatric nurse (CPN) visited Ms Mitchell at her home on December 6, 2010 and, while noting a decline in her mental health, and that she had no heating or hot water, did not act to address these issues, leaving them to be discussed at her next appointment on January 11, 2011.

On 20 December 2011, the last time they saw their daughter alive, her parents were horrified by her condition and phoned the CPN to detail their concerns. Ruth Mitchell was found dead by police officers at her St Budeaux home in 2012 after a neighbour raised concerns about her.

The Plymouth mental health team learnt of her death only three days later when they made enquiries after she failed to attend her second scheduled appointment in a row.

In 2016, a Parliamentary and Health Service Ombudsman report partially upheld the complaints made by Ruth’s parents and said: “Opportunities to prevent her deterioration and death were completely lost.”

In the same year, the Nursing and Midwifery Council found mental health nurse Joanne Elizabeth Campbell guilty of two charges relating to Ruth Mitchell’s death, one relating to record keeping and a second of not escalating safeguarding concerns, which amounted to misconduct.

In November 2017 a report put together by the Plymouth Safeguarding Adults Board highlighted 11 findings and made 12 recommendations for future practice, following scrutiny of the circumstances surrounding Ruth Mitchell’s death.

However, the Mitchells say this contradicted the post mortem report, which showed no alcohol in her body.

Mr and Mrs Mitchell believe their daughter starved herself, which led to the conditions that caused her death.

Mr Mitchell said: “Devon and Cornwall Police will hopefully investigate this matter thoroughly and bearing in mind the significant public interest, we hope that the police will liaise with the coroner to review the original inquest evidence and take into account everything that has since been revealed which the coroner was unaware of at the time and unable to examine."

A spokesman from Devon and Cornwall Police said: "A senior investigating officer has been appointed to meet with Mr and Mrs Mitchell to assess any fresh evidence they may have in relation to the death of Ruth Mitchell.

"A decision will then be made in due course, on if any further policing action will be taken in this matter."