A coroner has raised concerns about the treatment of a Malton woman before she died, and said there’s a risk of future deaths if nothing is changed.
North Yorkshire coroner Catherine Cundy presided over the inquest earlier this month into the death of Victoria Taylor, who was 34.
Now the coroner has sent a prevention of future deaths report to Tees Esk & Wear Valley NHS Foundation Trust (TEWV), which treated Ms Taylor.
It comes as York Central MP Rachael Maskell has called for a public enquiry into TEWV, citing “serious neglect and failures of safeguarding from the trust”.
In her report, Ms Cundy writes: “Ms Taylor’s mental health deteriorated significantly between May 2024 and her death, with an escalation in incidents of suicidal ideation, threatened and actual self harm, and episodes of binge drinking.
“Her suicidal ideation exhibited a preoccupation with going into the river, which she actually entered in July 2024 and from which she had to be extricated.
“Ms Taylor was reported missing from home on 1 October 2024. On 22 October 2024 her body was recovered from the River Derwent near Malton, North Yorkshire by an underwater search unit.”
Ms Cundy says that her inquiries raised concerns. “In my opinion there is a risk that future deaths could occur unless action is taken.”
She writes: “Ms Taylor was clear during all three assessments that her episodes of binge drinking and impulsive acts of self harm were the result of unresolved childhood trauma.
“Despite that, secondary mental health services considered there was no role for them in offering support or a treatment pathway to her.
“The safety plans agreed following these assessments were therefore limited and offered Ms Taylor no additional support beyond that which she was already accessing through the Horizons service.”
Read the full report
Instead of discussing treatment pathways to address the trauma through the Community Mental Health Team, “it was suggested at the second assessment that Ms Taylor may wish to refer herself to a named private psychotherapy service at some point in the future”.
The coroner goes on: “When Ms Taylor indicated at her third assessment that she had left a message with this private provider and received no response from them, the third safety plan simply suggested she try again.
“Mental Health services were aware at the time of the second and third assessments that a number of agencies were involved with Ms Taylor, but no multi-agency meeting or approach was suggested or called by them to consider the most appropriate support for Ms Taylor.”
Ms Cundy has said action should be taken, and TEWV has to respond by 31 October.
In response, Elspeth Devanney, group director for nursing and quality at Tees, Esk and Wear Valleys NHS Trust, said: “Following Victoria’s tragic death, we completed a review and have made changes to improve our services.
“We will respond to the coroner’s report and take action to continue to improve and provide high quality care to the people in our communities.”
‘Catastrophic consequences’
York Central MP Rachael Maskell today called for a public enquiry into the TEWV.
It comes after she was among a group of MPs from across the region who met with mental health minister Baroness Gillian Merron to lay out their concerns and issues with the NHS trust.
Ms Maskell said: “This meeting has come following serious neglect and failures of safeguarding from the trust, which have left people without adequate care.
“This has had catastrophic consequences, and tragically has meant vulnerable people have died in their services, despite warnings that they were at serious risk of harm.
What the trust says
A TEWV spokesperson said: “Our deepest sympathies remain with the families who have lost loved ones.
“As an NHS trust, we have no role or influence on public inquiries. These are a matter for the government. We will co-operate fully as required with openness and transparency.
“We work with some very vulnerable people, and continue to take every opportunity to improve the care we provide and have made substantial changes over the last few years.”
“I have received a great deal of correspondence from people impacted by TEWV’s failings, and met with several constituents in crisis, who have been let down by a system that they must depend on.
“It cannot continue in this current state, which is why we are urgently calling for better systems of accountability, and a full public inquiry into the Trust.”
Ms Maskell said the minister took MPs’ concerns seriously. She said she was “grateful to families, agencies and Healthwatch in York for bringing so many issues to my attention”.
Healthwatch York has two surveys about mental health underway. There is one for individuals here, and another for organisations here.
