A YORK woman took her own life following lapses in her mental health care during the first lockdown, an inquest heard.

Frances Wellburn was not visited by the community mental health team after lockdown began in March 2020 and suffered a relapse in May.

The 56-year-old, who suffered from psychotic depression, was found dead by police at her home in Main Street, Fulford, in August 2020, after her family raised the alarm.

Coroner Jonathan Leach, who described Frances as an 'independent, intelligent and resourceful' woman, said today that a review after her death had found lapses in her care, but it was not possible to say whether these had contributed to or caused her death.

Frances’ sister Rebecca told The Press afterwards that for 55 years, Frances had lived a ‘full and active’ life but in her final 10 months she had suffered from a serious episode of psychotic depression.

“There is every reason to believe that with the right care she would have recovered from this,” she said.

“Frances had indeed started her recovery in early 2020 and instead of building on this she was left with no contact by any means from her mental health team.

“We don’t believe her relapse in May was inevitable. It seems clear that it was linked to her stopping medication during the three month period where she had no contact from services.

“I’m pleased the coroner considered these events within the scope of the inquest. The significant gaps in care are an essential part of understanding the series of events that led up to her death.”

She said she hoped the Tees, Esk and Wear Valleys NHS Foundation Trust, which provides mental health care in York,recognised that more could have been done by it to support Frances’s recovery and prevent her tragic suicide.

Elizabeth Moody, director of nursing and governance at the trust, said: “Our hearts go out to Frances’s family and friends during this incredibly difficult time. We remain deeply sorry for their loss.

“Providing the best possible care for the people we support is the most important thing we do, and we have worked hard to make improvements following our own review into Frances’s tragic death in 2020.

“We shared our findings with Frances’s family and we are planning to work together to support further learning and improvement in our community mental health care.”

She said improvements included:

•The development of a carers forum to improve the experience of carers

• The splitting of two community mental health teams in York and Selby into four teams in September 2020, to provide better oversight of operational and senior clinical practice, increased capacity for managing caseloads and clinical supervision of staff.

• Training on the importance of the standard of documentation, particularly relating to the assessment, management and recording of clinical risk

• The introduction of practice development practitioners to support quality standards of care

• The refreshment of staff knowledge on operational policy relating to early intervention in psychosis and the criteria and processes of accepting referrals.

Contact York Samaritans at www.samaritans.org or telephone for free: 116 123