Julie’s death and inquest

Julie’s story

Julie first became seriously ill in early 2017. She was eventually sectioned for six weeks following an attempt on her life, after her family spent weeks attempting to get help for her.

She became ill again a year later. Again, her family struggled to get help for Julie.

This time, it ended in tragedy. Julie passed away on the 22nd of February 2018, after numerous interactions with mental health services in the weeks leading up to her death.

An inquest into Julie’s death was held in October 2018, running for four days. Julie’s family had to pay privately for a lawyer at the inquest, as they had no entitlement to state support.

The coroner, Dr. Peter Harrowing, gave a narrative verdict. He outlined nine failures in Julie’s care, including gross failures. He also found that Julie was a vulnerable person in need of care at the time of her death.

Below is a timeline of what happened to Julie in the last month of her life, the period covered by the inquest. It is based on the coroner’s verdict, notes released ahead of the inquest, and the experiences of Julie’s family.


30th January 2018

Julie first attempted to reach out to mental health services for help.

She was worried her medication was no longer working, so asked her mental health team for it to be reviewed. She was advised to call her GP.

The mental health nurse she called failed to record a plan for her care at this point. This information was not available subsequently to other staff. This was the first failure in Julie’s care.

2nd February 2018

Julie called her local mental health team again. Her call was answered by a member of administrative staff: an ‘unregistered practitioner’.

She was worried her condition was worsening, and asked for support.

Administrative staff are not permitted to make risk assessments. The staff member did so anyway. Julie’s risk was assessed as ‘low’.

The member of admin staff did not consult with a qualified nurse about Julie’s care. This was the second failure in her treatment.

The staff member also did not complete the notes on this decision, and the plan for Julie’s subsequent care.

3rd February 2018

Julie again calls her mental health team. During the phone call, although she denies planning to hurt herself, she refers to her hospital admission the year previously. She had been sectioned after attempting to take her own life.

In the phone call, she said that she was feeling ‘just as bad again’. She said repeatedly throughout the call that she ‘needed to come into hospital again’, and that she needed ‘to be seen by a doctor that day’.

Again, the phone call was taken by a member of administrative staff. She did not have the opportunity to consult a professional mental health nurse. Julie is told to contact her GP, and was advised to focus on ‘various tasks’: booking a meal with her husband for their wedding anniversary that evening.

The member of administrative staff does not realise the severity of Julie’s condition.

4th February 2018

Julie’s mental health team call her, and offer her an appointment for an assessment with a mental health nurse the next day.

This will be the only time during this episode she is seen in person by someone from her mental health staff team before she dies.

5th February 2018

Julie attends her appointment with a mental health nurse, and asks for treatment and support. She denies wanting to hurt herself. She says she feels ‘just as bad’ as when she was sectioned the year before following an attempt on her life.

At the inquest, the mental health nurse who saw Julie that day said that he ‘did not have a clear recollection’ of reading Julie’s previous notes – which were easily available to him.

Throughout the inquest, the Coroner raised concerns about staff workloads, and whether this prevented staff from having time to read their notes adequately.

That meant that the mental health nurse did not know about Julie’s suicide attempt the year before when making his assessment. The nurse did not understand what she meant when she said she was ‘just as bad’ as she had been then. Her notes also detailed that she was known to lie about her intentions to harm herself.

This was the fourth failure in her care. Her risk is therefore again assessed as ‘low’. She is referred to secondary services, which the nurse knows has a long waiting list, and that she is unlikely to be seen for several weeks. The dose of her medication is also slightly increased in consultation with a doctor.

10th February 2018

Julie again calls her local mental heath team. The call is answered by a mental health nurse. She says she is feeling ‘dreadful’ following the increase in her medication, but she refuses to give more information. She repeats that she is feeling ‘dreadful’ throughout the phone call.

The nurse suggests that she tries to focus on ‘small, achievable tasks’ over the weekend: for example doing some gardening. It should be noted that the weather outside at this point was extremely cold. He asks her to call again on Monday.

Following their call, the mental health nurse does not inform the nurse who previously assessed Julie about their phone call – although the nurse knows from Julie’s notes about her previous assessment, and that she is under his care. This was the fourth failure in Julie’s care.

At the inquest, when this nurse was asked why he didn’t inform his colleague, he said it was because he was ‘unable to access his emails’. He said that IT support was not available over the weekend. He was unable to explain why he didn’t ask a colleague to send an email on his behalf, or send an email himself on Monday.

10th – 18th February 2018

Julie had no contact with mental health services. No one from her local mental health team checked in on her during this period.

18th February 2018

Julie goes missing, briefly, for the first time. She isn’t home when her husband comes back from work, which is out of character for her. She does answer when he calls her. She says she will be back in 5 minutes, but does not return for an hour. She doesn’t explain where she has been.

19th February 2018

Julie is again missing when her husband comes back from work. Julie’s husband calls her mental health team, to find out if she has contacted them that day. A nurse tells Julie’s husband to call the police if he is concerned.

Julie’s family call the police, and find out that she has been in a road traffic accident on the M5, and is in hospital in Taunton. Driving on the motorway is extremely unusual behaviour for Julie.

Eye witnesses reported that Julie’s car had been seen swerving back and forth across several lanes of the motorway. Her car was hit by a lorry, and went on to hit the central reservation.

The M5 was closed in both directions for several hours due to the magnitude of the accident, and Julie had to be cut out of her car before being taken to hospital. Miraculously, she only suffered from minor cuts and some bruising.

Police are concerned that the car accident may have been a deliberate act of self-harm by Julie, due to her erratic behaviour.

She is assessed in Musgrove Park Hospital in Taunton, by their local mental health team. The mental health nurse who assessed her did not look at her previous notes, so was not aware of her previous attempts on her life, or that she would often lie about her intention to self-harm.

Julie denies that the car crash was intentional. However, she cannot give any explanation for why her car crash took place. The mental health nurse only speaks to Julie in front of her family, and at no point speaks to her alone.

Julie talks to the nurse about moving home soon. Her own mental health team had previously identified as a stressor in her life. The mental health nurse who assessed her decided that, as moving showed she had plans into the future, that they considered this a protective factor, which meant that she was unlikely to harm herself.

On this basis, Julie was discharged from hospital. No advice was given to Julie’s family on how to keep her safe. They were not told it was unsafe to leave Julie alone.

The mental health team at Taunton fail to pass on information about the crash and Julie’s assessment to her own mental health team. This was the fifth failure identified by the coroner in Julie’s care.

20th February 2018

Julie’s husband calls her mental health team. He tells them about her car accident on the motorway. Julie speaks to the mental health nurse on the line, and when asked how she is feeling, says that she is ‘not very good, not very good’. Julie is then silent. Julie’s husband asks for the team to send someone out to assess Julie, no one is sent.

Julie’s husband again calls her mental health team, and tells them that Julie’s mental health is deteriorating. He explains that she swerved several times across the motorway before crashing – and that going on the motorway at all is extremely unusual for her.

Julie’s husband is told that no one can come out today, but that a mental health nurse will call him tomorrow.

Julie’s husband explains that after tomorrow, as he is self-employed, he cannot afford to stay at home. He tells her mental health team he is going to take Julie to see her GP the next day, as he is not being helped by mental health services.

Julie speaks to the mental health nurse over the phone, but is monosyllabic. She indicates she cannot remember what happened in the car accident the day before. No one is sent to see Julie.

Julie’s husband makes an emergency appointment with her GP for the next day. However, when the appointment comes through, her doctor does not properly read all the information provided in the email about the accident. He is not aware of the level of Julie’s contact over the last month with her mental health team – and believes that responsibility for her lies with secondary mental health services, not with him.

The GP cancels the appointment Julie’s husband has made for her, which had been booked for the day before she went on to die. This was the sixth failure in Julie’s care. 

21st February 2018

Julie’s husband continues to call mental health services to ask for help for Julie, but no one comes to assess her. Her own mental health team have not assessed her following her car accident two days before. They do not refer Julie to the intensive team, this is the seventh failure in Julie’s care.

Later that day, Julie’s mental health nurse calls, and tells her husband he can see her on the 27th of February. She dies five days before she would have been seen.

When asked why he planned to wait so long before seeing Julie, her mental health nurse said he was concerned about the physical injuries from her car accident, and wanted her to be given a chance to recover – even though he knew that she only had minor cuts and bruising.

Her mental health nurse was more concerned with her physical health than her mental health.

Julie’s mental health nurse failed to make any assessment of her mental health during this phone call. His failure to do so was categories by the coroner as a gross failure in Julie’s care, and was the eighth failure in the care she received.

At the inquest, Julie’s mental health nurse admitted that had he assessed her properly, he would have referred her to the intensive mental health team immediately. Not referring Julie to the intensive team at this point was the ninth and final failure in her care.

After these failures became clear, a member of the intensive mental health team was asked to join the inquest, to explain what would have happened if Julie had of been referred. He looked up the cases on their books that day – and told the court that Julie would have been their number one priority. Someone would have been at her house within an hour, the night before she died. 

22nd February 2018

The day that Julie passes away

Julie goes missing again in the early hours of the morning.

Her husband tries to call her, but she has left her mobile phone behind.

Julie’s husband calls the mental health team in frustration – and tells them Julie has had ‘little to no aftercare’.

The police arrive – Julie is classified by the police as a high-risk missing person.

Julie’s husband calls her children and her elderly parents, to tell them she is missing.

The police search Julie’s house, the village she lived in, the area around her parent’s and her brother’s houses. Julie is not found.

A helicopter is deployed to look for Julie.

Julie’s husband, son and a neighbour help to search for Julie.

Julie is found in the evening, several hours after she first went missing, about 20 minutes away from her home.

She has already passed away.