Mum stunned by care 'failings' revealed after her daughter's death

The mother of a woman who killed herself by ingesting a poisonous substance she sourced online has criticised "failings 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 18 February 2023.

An inquest heard that her death followed a "significant reduction" in the support she was offered, leading to her mental state being "adversely affected."

An inquest at Nottingham Coroner's Court into Ms Langton's death heard she had bought the substance online, which she "deliberately ingested with the intention of bringing about her death."

Nottingham area coroner, Laurinda Bower, found decisions to reduce the support offered to Ms Langton "were often made in silo and on the basis of 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 many issues that adversely affected her mental state in the lead-up to her suicide."

The coroner later issued a prevention of future deaths report to various agencies in which she said: "Beth used the internet to research how to source and use [the substance] to bring about her death. She followed that guidance meticulously. That same guidance was still readily available on the internet at the time of her inquest, although I believe it might now have been removed.

"What system is in place to ensure that such websites are detected promptly and made unavailable to the public in a timely fashion?"

Ms Langton's mother, Shelley Macpherson, said the inquest revealed "worse" failings than she had imagined and told the BBC her daughter's mental health issues started when she was a teenager, and she was sectioned aged 17.

She said Ms Langton had received ongoing care, living outside of the family home and eventually moving to a flat at Oakwell House, a residential home for women with mental health conditions. 

Mrs Macpherson said: "When she first went to Oakwell House, she had 24/7 support from the staff and support from the community mental health team but in 2022, Nottinghamshire Healthcare NHS Foundation Trust discharged her saying she had enough support in the community."

She added that neither she, nor her daughter, had been comfortable with the change, particularly given the drugs Ms Langton had been prescribed but, as an adult, Ms Langton had to give permission for her mother to intervene in her care. 

Mrs Macpherson, 48, added: "That year, we had a difficult Christmas. From then onwards, until she died, she was not in a good place. She was disengaged with everything."

She said in the build-up to her daughter's death, Ms Langton had arranged to meet her council-appointed social worker and had asked to have all her "observation hours" at Oakwell House removed. It meant there was no obligation for staff to have one-to-one time with her.

Mrs Macpherson said: "We were shocked that the social worker agreed to that without consulting anyone else."

The night before Ms Langton died, she telephoned her mother, as was their routine on the days they did not meet.

Mrs Macpherson said: "She seemed more positive. She asked me if I was upset with her and I said, 'no of course not, I love you'. Looking back, that kind of makes sense now."

The next day, Mrs Macpherson was waiting for her daughter's call when two police officers knocked on her door with the news of her death.  

Mrs Macpherson said the evidence given to the inquest had been "astonishing and extremely distressing. We thought we knew there were failings and missed opportunities, but it was so much worse than we imagined. All I ask is that things are improved so this doesn't happen again."

Creative Care, which runs Oakwell House, said that, while the clinical psychologist contracted by Oakwell House, Gillian Merrill, had been self-employed and provided a "drop-in service for staff and residents", she "was not intended to replace any prescribed care package.”

A spokesman said: "The decision as to the level of support received by service users in the form of a care package is determined by medical professionals and social services and not Creative Care.

"We are aware of the coroner's concerns around a misunderstanding about services that led to a disjointed package of care, and steps have been taken to improve interagency communications."

Executive medical director and deputy chief executive of Nottinghamshire Healthcare NHS Foundation Trust, Dr Susan Elcock, 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."

Executive director of adult social care and health at Nottinghamshire County Council, added, Melanie Williams, said: "Nottinghamshire County Council carries out regular reviews of its practices and the support it offers and will always make any improvements that may be required."