The family of a woman who took her own life while inside a mental health unit in Hull say their concerns over her welfare were ignored by mental health professionals.
Michelle Ahmed, 41, suffered a series of setbacks in 2021, including the breakdown of her long-term relationship which deeply affected her, sparking issues with her mental health. The Covid pandemic had a negative impact on her work as well, while her beloved dog also died.
During the summer of 2021 she had attempted suicide on a couple of occasions and was sectioned. Michelle, of Hull, later expressed regret over the suicide attempts and admitted it was distressing for her family.
But Michelle's mental health deteriorated around the start of October and she was eventually given a bed at the Avondale unit at Miranda House in Hull as part of a voluntary referral recommended by her community mental health nurse.
She checked into the unit on October 6, 2021 where she was to undergo a seven-day assessment to find out how best to treat her mental health issues. However, just three days later, on October 9, she was found unconscious in the female lounge area in the unit after self-harming. She died three days later at Hull Royal Infirmary.
On the second day of the inquest into her death, statements were read out from family members who expressed frustration their concerns for Michelle were not being heeded by mental health staff.
No history of mental health issues
In a statement, Michelle's son Ethan outlined his concerns over the care his mum received from the different mental health teams. He said his mum - a care assistant - had suffered no mental health problems prior to 2021 but the problems started when his mum and her partner of 18 years split up.
In his statement, Ethan said: "After the separation, mum would come home upset and crying. She contacted the doctor and he gave her medication but I didn't think it worked and she cried almost every day."
In June, Michelle's mental health deteriorated and she ended up being sectioned. She was sent to a mental health unit in Harrogate but her mental health continued to suffer. Michelle later went to Miranda House and then to a mental health unit in Darlington before returning to Westlands in Hull.
Ethan noticed a big improvement in his mum in September but, sadly, she began to deteriorate once more. At the start of October, Michelle became more agitated and wanted to be referred to a mental health unit.
Michelle had overdosed on medication and went to Hull Royal Infirmary. Meanwhile, Beverley Shepherd, who is a mental health nurse with the community team in Hull, tried to find Michelle a bed but was unable to get one over the weekend.
Ethan said: "Mum was very agitated and wanted to be in a mental health unit. At one point she reached for a knife but I managed to stop her. I felt she should have been sectioned for her own safety."
A bed at Avondale was eventually found for Michelle on Wednesday, October 6, 2021. But Ethan expressed concerns his mum was being ignored.
He said: "My mum was upset when she was told by doctors they were planning to discharge her on the Monday. She was distressed and upset and felt she was not being listened to. She felt no one was helping her. I spoke to her on October 9 and she seemed a little agitated but generally okay."
'Mum was let down by the NHS'
But less than two hours after speaking to his mum, Ethan received a call from Avondale telling him to go to A&E. Michelle had made another attempt on her life and she died three days later in Hull Royal Infirmary on October 12.
In his statement, Ethan said: "I feel my mum was let down by the NHS. She asked for help and was not listened to. As a family we had to fight for help but it was not enough."
Michelle's sister-in-law Louise Lyell also outlined how Michelle's mental health had deteriorated rapidly.
She said: "Michelle was a lovely, bubbly person who was always the first person there for me. I was not aware she had any mental health problems until March 2021.
"I had known her for 18 years when she started seeing my brother. But then they split up in 2021 which was a shock to me. But Michelle was struggling with the separation."
Louise described how Michelle's mental health deteriorated over the months.
She said: "Michelle's life was turned upside down but she had all the support in the world from family and friends. But we are not professionals.
"The problem was she could not explain how she was feeling so things were getting missed. We expressed concerns about certain decisions but we always got ignored. I feel that, if mental health services had listened to us months before, Michelle would not have done what she did to herself."
The inquest also heard from independent expert Alex Hamlin who investigated Michelle's death and produced a serious incident report which made 18 recommendations.
The consultant psychologist concluded that, while there were improvements to be made following the review of Michelle's care, no one issue contributed directly to her death. The main concern she raised in her report centred round the involvement of Michelle's family.
Ms Hamlin said: "It was clear how important her family was to Michelle. There were missed opportunities to increase the family's involvement in Michelle's care. The family's views were not always sought.
"The family were frustrated as they were not sure who to contact during a crisis. It was a missed opportunity not to have the family better informed as they were so close to Michelle."
Ms Hamlin also raised concerns there were different expectations between the mental health team, Michelle and the family over what treatment and care plan Michelle would receive at the Avondale unit. Michelle was focussed on medication but the staff at Avondale wanted to focus on coping strategies.
Michelle felt 'ignored'
Ms Hamlin also highlighted concerns that Michelle felt ignored as doctors were planning to discharge her on the Monday.
She said: "Michelle felt doctors were not listening to her. She said she was scared to go home and was worried she would do something. She was distressed and upset at that time and it was not the right time to discuss her care plan."
Many of Ms Hamlin's recommendations centred round increased staff training and putting in place ways to better record decisions and care plans. She revealed the Humber Teaching NHS Foundation Trust had implemented all but one of the recommendations to date.
But she did focus on ensuring that, where patients want their family to be fully involved in their care, loved ones are informed and consulted.
She said: "Staff at Avondale now have training on family inclusion in the care of patients. There needs to be a written safety plan which can be accessible and understood by the patient and the family so they know how to act during a crisis."
She also raised concerns about the difference between Michelle's expectations regarding treatment and what Avondale can provide.
She said: "There needs to be a clear understanding of what the aim is when a patient attends Avondale, what the patient can expect and what the pathway is for in-patient care."
No one failing caused Michelle's death
Despite a long list of recommendations and improvements identified, Ms Hamlin did not feel any fundamental mistake was made which contributed to Michelle's death.
She said: "On the balance of probabilities, these issues would not have made a difference to the outcome in Michelle's case. None of them are root causes. Even with all these improvements in their totality, I don't think it would have prevented her death."
The inquest also heard that it was also unclear how long it was between Michelle last being seen on CCTV or by staff members and when she was found unconscious. There had been claims she was seen just a few minutes before she was found but the last CCTV footage of Michelle was from 6.51pm – some 40 minutes before.
The inquest continues and is expected to finish on Wednesday.
Hull Daily Mail
Michelle Ahmed, 41, suffered a series of setbacks in 2021, including the breakdown of her long-term relationship which deeply affected her, sparking issues with her mental health. The Covid pandemic had a negative impact on her work as well, while her beloved dog also died.
During the summer of 2021 she had attempted suicide on a couple of occasions and was sectioned. Michelle, of Hull, later expressed regret over the suicide attempts and admitted it was distressing for her family.
But Michelle's mental health deteriorated around the start of October and she was eventually given a bed at the Avondale unit at Miranda House in Hull as part of a voluntary referral recommended by her community mental health nurse.
She checked into the unit on October 6, 2021 where she was to undergo a seven-day assessment to find out how best to treat her mental health issues. However, just three days later, on October 9, she was found unconscious in the female lounge area in the unit after self-harming. She died three days later at Hull Royal Infirmary.
On the second day of the inquest into her death, statements were read out from family members who expressed frustration their concerns for Michelle were not being heeded by mental health staff.
No history of mental health issues
In a statement, Michelle's son Ethan outlined his concerns over the care his mum received from the different mental health teams. He said his mum - a care assistant - had suffered no mental health problems prior to 2021 but the problems started when his mum and her partner of 18 years split up.
In his statement, Ethan said: "After the separation, mum would come home upset and crying. She contacted the doctor and he gave her medication but I didn't think it worked and she cried almost every day."
In June, Michelle's mental health deteriorated and she ended up being sectioned. She was sent to a mental health unit in Harrogate but her mental health continued to suffer. Michelle later went to Miranda House and then to a mental health unit in Darlington before returning to Westlands in Hull.
Ethan noticed a big improvement in his mum in September but, sadly, she began to deteriorate once more. At the start of October, Michelle became more agitated and wanted to be referred to a mental health unit.
Michelle had overdosed on medication and went to Hull Royal Infirmary. Meanwhile, Beverley Shepherd, who is a mental health nurse with the community team in Hull, tried to find Michelle a bed but was unable to get one over the weekend.
Ethan said: "Mum was very agitated and wanted to be in a mental health unit. At one point she reached for a knife but I managed to stop her. I felt she should have been sectioned for her own safety."
A bed at Avondale was eventually found for Michelle on Wednesday, October 6, 2021. But Ethan expressed concerns his mum was being ignored.
He said: "My mum was upset when she was told by doctors they were planning to discharge her on the Monday. She was distressed and upset and felt she was not being listened to. She felt no one was helping her. I spoke to her on October 9 and she seemed a little agitated but generally okay."
'Mum was let down by the NHS'
But less than two hours after speaking to his mum, Ethan received a call from Avondale telling him to go to A&E. Michelle had made another attempt on her life and she died three days later in Hull Royal Infirmary on October 12.
In his statement, Ethan said: "I feel my mum was let down by the NHS. She asked for help and was not listened to. As a family we had to fight for help but it was not enough."
Michelle's sister-in-law Louise Lyell also outlined how Michelle's mental health had deteriorated rapidly.
She said: "Michelle was a lovely, bubbly person who was always the first person there for me. I was not aware she had any mental health problems until March 2021.
"I had known her for 18 years when she started seeing my brother. But then they split up in 2021 which was a shock to me. But Michelle was struggling with the separation."
Louise described how Michelle's mental health deteriorated over the months.
She said: "Michelle's life was turned upside down but she had all the support in the world from family and friends. But we are not professionals.
"The problem was she could not explain how she was feeling so things were getting missed. We expressed concerns about certain decisions but we always got ignored. I feel that, if mental health services had listened to us months before, Michelle would not have done what she did to herself."
The inquest also heard from independent expert Alex Hamlin who investigated Michelle's death and produced a serious incident report which made 18 recommendations.
The consultant psychologist concluded that, while there were improvements to be made following the review of Michelle's care, no one issue contributed directly to her death. The main concern she raised in her report centred round the involvement of Michelle's family.
Ms Hamlin said: "It was clear how important her family was to Michelle. There were missed opportunities to increase the family's involvement in Michelle's care. The family's views were not always sought.
"The family were frustrated as they were not sure who to contact during a crisis. It was a missed opportunity not to have the family better informed as they were so close to Michelle."
Ms Hamlin also raised concerns there were different expectations between the mental health team, Michelle and the family over what treatment and care plan Michelle would receive at the Avondale unit. Michelle was focussed on medication but the staff at Avondale wanted to focus on coping strategies.
Michelle felt 'ignored'
Ms Hamlin also highlighted concerns that Michelle felt ignored as doctors were planning to discharge her on the Monday.
She said: "Michelle felt doctors were not listening to her. She said she was scared to go home and was worried she would do something. She was distressed and upset at that time and it was not the right time to discuss her care plan."
Many of Ms Hamlin's recommendations centred round increased staff training and putting in place ways to better record decisions and care plans. She revealed the Humber Teaching NHS Foundation Trust had implemented all but one of the recommendations to date.
But she did focus on ensuring that, where patients want their family to be fully involved in their care, loved ones are informed and consulted.
She said: "Staff at Avondale now have training on family inclusion in the care of patients. There needs to be a written safety plan which can be accessible and understood by the patient and the family so they know how to act during a crisis."
She also raised concerns about the difference between Michelle's expectations regarding treatment and what Avondale can provide.
She said: "There needs to be a clear understanding of what the aim is when a patient attends Avondale, what the patient can expect and what the pathway is for in-patient care."
No one failing caused Michelle's death
Despite a long list of recommendations and improvements identified, Ms Hamlin did not feel any fundamental mistake was made which contributed to Michelle's death.
She said: "On the balance of probabilities, these issues would not have made a difference to the outcome in Michelle's case. None of them are root causes. Even with all these improvements in their totality, I don't think it would have prevented her death."
The inquest also heard that it was also unclear how long it was between Michelle last being seen on CCTV or by staff members and when she was found unconscious. There had been claims she was seen just a few minutes before she was found but the last CCTV footage of Michelle was from 6.51pm – some 40 minutes before.
The inquest continues and is expected to finish on Wednesday.
Hull Daily Mail
