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Inquest finds that neglect contributed to the death of Angela Ling, aged 49

07 Jul Inquest finds that neglect contributed to the death of Angela Ling, aged 49

A seven-day inquest held at Chelmsford Coroner’s Court has concluded that 49-year-old Angela Ling died as a result of suicide contributed to by neglect on the part of Essex Partnership NHS Trust.

The inquest, which concluded on 28 June 2024, heard how Angela Ling took her own life while she was under the care of Essex Partnership University Trust (EPUT) for a diagnosed recurrent Major Depressive Disorder. Evidence was heard by HM Coroner Sean Horstead at Chelmsford Coroner’s Court.

Angela, from Chelmsford, Essex, died on 1 December 2021. The inquest investigated the care and treatment provided to her while she was struggling with her mental health and required support from EPUT.

Expert evidence to the inquest highlighted that Angela received no effective care or treatment for her major recurrent depressive disorder throughout her time under the care of EPUT. The expert Dr Dinesh Maganty said that, had Angela received the care and treatment she needed, she would have likely survived.

The coroner found several failings in Angela’s care, which included:

Failure to consult with Angela’s family throughout her care journey
Failure to provide consistent pharmacological treatment
Failure to provide any psychological treatment
On 16 October 2021, Angela was assessed under the Mental Health Act (MHA), however she was discharged home as there were no beds available. On 18 October 2021 a bed was found and Angela was admitted to Galleywood Ward in the Linden Centre in Chelmsford.

There, Angela was diagnosed with major recurrent depressive disorder and was discharged on 26 October 2021 into the care of EPUT’s Home Treatment Team (HTT). Despite showing concerning behaviours, including having thoughts to end her life and attempting an overdose on 29 October 2021, Angela was discharged into the less intensive service of the Community Mental Health Team (CMHT) on 8 November 2021.

The inquest heard that while under the care of the HTT and CMHT, Angela’s mental health deteriorated, and she attempted to overdose four times. Throughout this period, Angela’s family were working tirelessly to keep Angela safe. Her children at that time (aged 17, 19, 21 and 22) reported to the professionals at the HTT and CMHT that they could not keep her safe, that her behaviour was erratic and delusional, and that she presented very differently to professionals than to her family. 

On 17 November 2021, following an overdose, Angela was taken to Broomfield Hospital. The court heard that Angela’s care coordinator made it known to EPUT’s gatekeeping team that Angela needed inpatient care, that she was hoarding her medication, and her family and the CMHT could not keep her safe.

EPUT’s gatekeeping team assessed Angela on 19 November 2021. She was not referred for an MHA Assessment despite the care coordinator notifying them of her opinion that she required inpatient care. Angela’s family told the inquest that they were not contacted at any time regarding her care plan or for any information gathering.

Angela was discharged home on 19 November. She had two at home meetings with EPUT’s Home Treatment Team on Saturday 20 November and Sunday 21 November. The expert at the inquest said Angela should have been referred for an MHA Assessment on 19 November 2021 and on 21 November 2021.

On Sunday 21 November, the professionals in attendance noted that Angela was distressed, catastrophising and unable to rationalise and process information. At this meeting, Angela reported she was going to end her life by overdose but had no medication in the house. Her care was not escalated at this stage and her family were not offered any additional support. Later that day, Angela attempted to take her own life. She was taken to hospital and after receiving a period of intensive care it was determined that Angela has suffered irreversible brain damage. Angela died on 1 December 2021. 

The Coroner delivered his conclusions on Friday 28 June 2024 and has listed a further hearing to hear Prevention of Future Death issues on 15 July 2024.

Angela’s family are represented by Leigh Day human rights partner Anna Moore who instructed Sophie Walker from One Pump Court.

In a joint statement, Angela’s children said:

“Our mum was just 49 when she died. She was above all our mum, the most important job in the world to her, and we loved her more than we could put into words. Our hearts have been broken because she deserved better and so much longer, and it was a death that should have been avoidable.

“She was kind, generous, clever, bubbly and fun. She was feisty, tenacious and held strong opinions and was well educated entirely by her own determination. She loved spending time with her family and dogs.

“We were doing all we could to get mum the support she needed and we are glad the coroner recognised this in his conclusions. Sadly mum did not get the help she needed but we hope things will change to mean that others are not put in the same position that we were.”

As part of the pen portrait read out in court, Angela’s mother said:

“Angela was never a person to do things by halves, in her own words, “you know me Mum, I’m all or nothing”. She was a loving Mum and fiercely protective of her children, her family, her home but mostly her children were everything to her.

“She had in the past talked of looking ahead to her retirement years. She told me she just wanted to potter in her home, tend her garden, grow herbs and vegetables. She had talked of wanting to extend the family home, so that her children could bring their children home for family events. She had recently said she wanted to travel and to have family holidays. However, tragically, this future was not to be.

“Above all, she was our beautiful, precious, irreplaceable daughter and we loved her beyond measure.”

Leigh Day partner Anna Moore said:

“The mental health services at Essex are already under scrutiny by way of an Independent Inquiry as clearly things are going wrong at the Trust. There were clear and serious deficiencies in the care offered to Angela and her family and I hope, instead of adopting a defensive approach, EPUT take steps to carefully consider the conclusions of the Coroner and take steps to make things safer for patients in the future.”