Mother astonished by agency’s “failures” before her daughter’s death

The mother of a woman who committed suicide by ingesting a toxic substance she obtained online has criticized “failures and misunderstandings” in the care of her daughter.

Beth Langton, 22, who had been diagnosed with a personality disorder and complex post-traumatic stress disorder, was discovered at her home in Retford, Nottinghamshire, on February 18, 2023.

An inquest found that her death was due to a “significant reduction” in the support offered to her, which had resulted in “adverse impairment” of her mental state.

Shelley Macpherson, Ms Langton's mother, said the investigation had uncovered “worse” failings than she had imagined.

Ms Macpherson told the BBC that her daughter's mental health problems began when she was a teenager and she was admitted to a clinic at the age of 17.

She said Ms Langton received ongoing care, lived away from home and eventually moved into a flat at Oakwell House, a residential home for women with mental illness.

“When she first came to Oakwell House, she received 24-hour support from staff and the community mental health team,” Ms Macpherson said.

“But in 2022, the NHS Trust [Nottinghamshire Healthcare NHS Foundation Trust] dismissed her on the grounds that she had enough support in the community.”

She added that neither she nor her daughter were happy with the change, especially given the medication Ms Langton had been prescribed.

As an adult, Mrs Langton had to give her mother permission to intervene in her care.

Mrs Macpherson, 48, said: “We had a difficult Christmas that year. From then until she died she was not well. She was excluded from everything.”

She said that in the run-up to her daughter's death, Mrs Langton had arranged a meeting with her council-appointed social worker and asked for all her “observation hours” at Oakwell House to be cancelled. This meant that staff were no longer required to spend time with her face-to-face.

Ms Macpherson said: “We were shocked that the social worker agreed to this without consulting anyone else.”

The night before Mrs Langton's death, she called her mother, as was her routine on days when they did not see each other in person.

“She actually seemed more positive. She asked me if I was mad at her and I said, 'No, of course not, I love you,'” Ms Macpherson said.

“Looking back, it somehow makes sense now.”

The next day, Mrs Macpherson was waiting for her daughter's call when two police officers knocked on her door and broke the news of her death.

Ms Macpherson said her daughter had talked about wanting to be “normal like everyone else”.

“Beth was very creative – she had a great talent for writing poetry and often used it to deal with her feelings. We have many of her poems now,” she said.

“As a child, she was a carefree little girl. She loved doing things, especially if it was something she could win at. She tried everything.”

An inquest into Ms Langton's death concluded at Nottingham Coroner's Court last month.

It was said that she had obtained the substance on the Internet and taken it “with the intention of causing her death”.

Coroner Laurinda Bower found that decisions to reduce the support offered to Ms Langton were “often made in isolation and on the basis of inaccurate information about the support Beth received”.

In her documented findings, Ms Bower said: “The withdrawal of support led to feelings of abandonment and rejection that are related to Beth's personality disorder.”

“These feelings of abandonment and rejection were one of many issues that negatively affected her mental state leading up to her suicide.”

The coroner later released a report to various agencies to prevent future deaths.

In the report she said: “Beth used the Internet to research how to [the substance] to cause her death. She followed this instruction to the letter. This instruction was still available online at the time of her investigation, although I believe it may have since been removed.

“What system is in place to ensure that such websites are promptly identified and removed from the public in a timely manner?”

Leigh Day Solicitors, which represented Ms Langton's family at the inquest, said it had received information from Gillian Merrill, a clinical psychologist contracted to Oakwell House.

The company said Oakwell and Ms Merrill had no written contract or terms of reference for her role or the support she would provide to Ms Langton.

Leigh Day said this “volatile” arrangement had “led to significant misunderstanding between the agencies involved in Beth's care”.

This included concerns raised in spring 2022 about Ms Langton’s dismissal from Nottinghamshire Healthcare NHS Foundation Trust “for the first time in over a decade”.

“The coroner heard evidence that the decision was made largely based on a misunderstanding of Ms Merrill's role and the psychological services she provided to Beth,” the company said.

“It is documented that Beth herself informed the mental health team at the time that she was not receiving the support she expected. Her care coordinator acknowledged this at the inquest and should have led to a reconsideration of her discharge.”

Ms Macpherson said the evidence presented at the inquiry, which closed on July 8, was “astonishing”.

“It was extremely disturbing,” she said.

“We thought we knew there were oversights and missed opportunities, but it was much worse than we imagined.

“I'm just asking that things get better so that something like this doesn't happen again.”

If you are affected by any of the issues raised in this story, you can BBC Action Line.

Creative Care, which operates Oakwell House, said that while Ms Merrill was self-employed and offered an “open service to staff and residents”, the psychologist was not intended to be “a substitute for prescribed care packages”.

“The decision about the level of support service users receive in the form of a care package is made by healthcare professionals and social services and not by Creative Care.

“We are aware of the coroner's concerns about a misunderstanding over services which has resulted in a disjointed treatment package and steps have been taken to improve communication between agencies,” a spokesman added.

Dr Susan Elcock, chief medical officer and deputy chief executive of Nottinghamshire Healthcare NHS Foundation Trust, said: “We are working with our partner agencies to address the issues raised by the coroner and improve the care of our current and future patients.”

Melanie Williams, chief executive of adult social care and health at Nottinghamshire County Council, added: “Nottinghamshire County Council regularly reviews its practices and the support it offers and will always make any improvements necessary.”