Original complaint to Somerset Partnership – 21st October 2018

Dear Sir/Madam

My mum (Julie Montacute) was treated at Musgrove Park Hospital on the 19th of February this year following a road traffic accident. Police reported that she had swerved across several lanes of the motorway, before pulling in front of a lorry, which hit her into the central reservation (https://www.bristolpost.co.uk/news/bristol-news/woman-who-weaved-across-m5-2112122)
Staff in both A&E, and the police, were concerned that the crash was intentional, and an attempt by my mum to end her own life. A nurse from the on call mental health team, Anthony Garlick, came to assess her. During the inquest into her death last week, it was heard in his evidence that he did not ask my mum why she swerved across the motorway, or why she pulled out in front of the lorry, despite the concern from staff in A&E and the police. He only asked mum if the crash was an accident, without examining this, and took her word for it. If he had looked at her notes (she was under the Avon and Wiltshire mental health trust), he would have known she had previously made attempts on her life which she had denied afterwards. During the inquest, the coroner was shocked that Mr Garlick did not fully examine the reasons mum had ended up in the accident, instead of only asking why she was out for a drive in the first place. The accident itself was not examined in his assessment of her.
Additionally, he only spoke to mum with her husband present. Patients often do not want to admit suicidal thoughts in front of their loves one, and I believe that only asking patients with family members present is a danger to their safety.
He also told the inquest that the reason he assessed her as safe, and that she would not take her own life, was because she “had plans for the future” because she planned to move house. Garlick made his own decision that this was a positive in her life – although other mental health nurses who assessed mum had identified the house move as a source of stress for her mental health.
He, together with another mental health nurse working with him (I apologise as I don’t know their name, as they were not questioned at the inquest) appear to have failed to send through information about the assessment carried out on my mum that night to her mental health team or her GP for days (the letter was dated the 21st). This was identified as a failing in mum’s care by the coroner in a finding of fact after the inquest. My mum died on the 22nd, after drowning in the lake near our house, having had no support for her mental health following her release from Musgrove Park Hospital. Mr Garlick was the last mental health professional to assess her in person.
I am seriously concerned that, were a case like my mum’s to come into Musgrove Park Hospital today, they would still not be assessed properly, and therefore that their treatment would not be safe. Can you please let me know what you plan to do in light of the findings of the inquest to ensure patient safety. Can this please include full details of how mental health nurses are trained in risk assessment at the hospital, and what steps are being taken to ensure a case like this cannot happen in future.
If you wish to speak to me in person, I’m happy to provide any further information as required.
Dr Rebecca Montacute