The inquest into the death of Melanie Hart concluded earlier this week (14th May 2024) and was heard over four days at Bolton Coroners Court in front of HM Senior Coroner Timothy Brennand.
Prior to the deterioration in her mental health, Melanie had so much to live for. She was a mother who lived a rich and fulfilling life with a loving family. Due to a variety of circumstances and events, she fell into a pattern of behaviour of drink and drug dependency and her mental health subsequently deteriorated. Melanie sadly died of multiple injuries including a severe head injury on 14th June 2023 having deliberately positioned herself in front of a train on the West Coast Mainline.
Circumstances:
Melanie had a complex medical history which included polysubstance misuse with co-occurring mental health issues incorporating enduring anxiety and depressive disorders, drug-induced first episode psychosis with recurring auditory hallucinations with delusional and cognitive impairment. Her established relapse profile included phases of persistent emotional dysregulation, suicidal and self-harming behaviours, and non-concordance with treatment driven by multiple factors, but primarily were drink and drug-induced.
Despite active community and phases of inpatient care, including inpatient detention pursuant to s2 of the Mental Health Act 1983 between 30th March – 20th April 2023; and 21st May – 3rd June 2023 Melanie’s condition deteriorated.
In the early hours of 14th June 2023, Melanie was seen by concerned members of the public behaving erratically and in a distressed manner. Police Officers attended, persuading her to voluntarily attend Royal Albert Edward Infirmary, Wigan, where after initial treatment to possible concerns as to her physical well-being, she was to self-discharge prior to being seen by a Mental Health Liaison Team (MHLT), a fact not brought to their attention.
Later in the morning Melanie was seen on the streets in a hospital gown and was observed to change into clothes, but in a visibly distressed and agitated state, requesting to be taken to Atherleigh Park Psychiatric Hospital. Attending police officers again considered it in Melanie’s best interest to voluntarily attend at Royal Albert Edward Infirmary, but did not deem it necessary to detain her pursuant to the provisions of s136 of the MHA 1983. These powers, under the Mental Health Act 1983, allow officers to remove a person to a place of safety without a warrant if they appear to be suffering from a mental disorder and are in immediate need of care or control.
Melanie later arrived that same morning. Following her re-admission at the A&E department, Melanie began to behave in an erratic, incoherent, aggressive, and highly agitated state expressing delusional beliefs, for reasons that were not established and were considered attributable to her mental health episode presumed to be associated with her longstanding and known polysubstance misuse. Her conduct included climbing on the hospital roof and other infrastructure, damaging property, and assaulting a member of staff. Melanie required lawful restraint by hospital security personnel. Police were called but determined her behaviour to be related to her mental health condition which they assumed was being dealt with and declined to invoke their s136 powers. Healthcare staff considered Melanie to be experiencing a drug/alcohol-induced deterioration until an assessment from the Alcohol and Substance team later revealed that she was not.
By reason of significant operational demand upon the MHLT service, Melanie was not clinically assessed by a trained mental health practitioner until 4 pm that afternoon. During the assessment, Melanie disclosed that if she were to leave the hospital, she would jump in front of a train. Melanie explained that she had not received her planned depot antipsychotic medication from her local Community Mental Health Team (CMHT). She disclosed auditory and visual hallucinations with an active plan to end her own life. Despite this, the practitioner deemed Melanie to have capacity and that she ought to be admitted, on a voluntary basis, to an inpatient mental health ward, placing her on hourly observations whilst awaiting a hospital bed to be assigned.
No diagnosis or medication review occurred nor was it considered necessary for a formal mental health assessment or to seek the opinion of the duty psychiatrist and so created a missed opportunity to appreciate the reality that in fact Melanie was suffering from fluctuating capacity by reason of a serious relapse of her underlying psychotic illness creating an enduring, significant, real and immediate risk of self-harm and suicide requiring a maximal pathway of interim treatment and care. The family were not contacted.
Melanie was last seen by MHLT staff at 6 pm noted to be ‘sleeping’ in a side room. By 6:15 pm Melanie had absconded from the hospital. This was reported to the police at 6:56 pm. By 6:27 pm GMP received a call from a concerned member of the public in relation to Melanie. This became a Grade 1 immediate risk call. Between 6:29 pm – 6:32 pm, an off-duty officer reported Melanie on a railway track adjacent to Spencer Road, Wigan.
British Transport Police were informed of Melanie’s presence at 6:36 pm.
At 6:40 pm Melanie was struck by a Royal Mail freight train, despite the driver attempting to brake and having sounded the train’s horn, Melanie was seen deliberately positioning herself in front of the train when she was struck, sustaining immediate and fatal head and other injuries.
The Coroner raised concerns with a number of the interested persons describing their lack of responsibility towards the care of Melanie as a ‘Mexican stand-off’ situation, where no agency took adequate control to ensure Melanie’s safety.
In respect of Royal Edward Infirmary, the Coroner noted that had the full clinical extent of her relapse profile been appreciated by the Mental Health Liaison Team on 14th June 2023, combined with sub-optimal elements including delayed triaging and care, inadequate communication processed staff shortages and missed opportunities to consider the true etiology of her relapse, with the resulting failure to recognise that a formal Mental Health Act assessment was necessary.
Additionally, having heard numerous Inquests involving issues with the standard of care at the Royal Edward Infirmary, the Coroner was frustrated that there can be as many as 4/5 patients awaiting inpatient mental health treatment, emphasising that this situation occurs far too frequently, citing issues with staff retention, recruitment, training, shift management and the need for dedicated resources as recurring themes that need to be addressed. The Coroner even committed to personally visiting the ‘Makerfield Suite’, the dedicated space for patients experiencing a mental health crisis who present at the Emergency Department to see the changes firsthand.
Regarding the role of Greater Manchester Police, DCI Jane Curran, the strategic lead for mental health stated that police have been criticised often by mental health trusts for overusing s136 powers. This was deeply concerning because it risks leaving individuals like Melanie, who are in crisis, without the necessary support and intervention at a time when they are most vulnerable.
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