A “sweet” student was found dead at home after ‘not fitting’ into the mental health services system, an inquest heard.
Denise Ann Rayter, 24, had been splitting time between her family home in Bristol and a supported living facility in Plymouth, where she was studying a masters at university, receiving mental health treatment in both cities.
Plymouth Coroner’s Court heard Denise had been diagnosed with a number of mental health issues in 2017, including personality disorder with psychotic traits, resulting in admissions at the Glenbourne Unit and Greenfields mental health inpatient unit in Plymouth.
Denise was adopted aged 11, after her birth mother took her own life when she was just nine years old, Plymouth Live reports.
She was in touch with North Bristol Crisis Service and staying at Westward Housing’s Hill Park Crescent support services facility, when she sent a worrying text to her adoptive mother the day before her death.
The following day, after mother called the facility with concerns about not hearing from her daughter, Denise was sadly found dead in her room by a support worker, on November 29 last year.
‘Didn’t fit anywhere’
Senior Coroner Ian Arrow, who recorded the cause of death as a suicide by hanging, said he would write to the suicide reduction group and ask for a review to be conducted regarding Denise’s death.
Rachel Cruise, operations director at The Zone, explained a route cause analysis was undertaken after Denise’s death and a number of points were found.
She said that whilst “good communication was maintained between Plymouth and Bristol” and alternative methods such as family therapy via Skype were used, there were a number of issues.
The “suicide risk assessment hadn’t been completed” and neither had a “professionals’ risk meeting” been called.
Ms Cruise said: “Practitioners felt there was a gap in the services and Denise didn’t fit anywhere.
“There was lack of evidence that discussions had been held. We felt there was no clear cause of Denise’s death.”
Mr Arrow added: “There does not seem to have been a suicide assessment completed in a timely way.”
Ms Cruise responded that Denise’s suicidal tendencies were “assessed and recorded”, but “it wasn’t pulled through to a formal suicide risk assessment”.
Her heartbroken mother, Ann Rayter told the court her beloved daughter “had changed” and they were left “confused” by a number of diagnoses, including “attachment disorder” which resulted in her and her husband being instructed to see their daughter less.
She told the coroner’s court: “Things have not been done, it is full of lost opportunites. I know you say there were no lost opportunities, but the sentence that stands out for me was ‘Denise did not fit anywhere’. How can that be the case?
“There is a flaw and I do feel there is a huge gap here that all this paperwork. However you explain it, in Glenbourne, things were not recorded.
“For me as a parent and a professional, when you read lessons have been learned, it means someone has died and this young woman was my daughter and my husband’s daughter.”
Mrs Rayter added: “There’s no wedding to attend, no grandchildren, no degree to collect, we collected it. We have actually attended her graduation and it was awarded to her. We are her voice now.
“We trusted Plymouth and we feel very let down that no one seems to have come to a conclusion. She was very much loved.”
The inquest heard Denise described as a “sweet” young woman.
‘A lot to live for’
Mr Rayter added that “getting the risk assessment wrong [was] critical”.
As a result of Denise’s death, Westward Housing staff have undergone suicide prevention risk training and the insight team have changed its processes and now all case discussions have to undergo a risk meeting.
There has also been the appointment of a full-time psychiatrist and two assistant psychiatrist to the team.
Officer in the case, DC Chris Wooland from Charles Cross Police Station, said there was “no sign of any disorder, no sign of any third party involvement and it appeared it was a suicide by hanging”.
Toxicology reports found Denise had no drugs or alcohol in her system.
Mr Arrow said: “I’d like to thank the witnesses, most importantly I would like to thank Denise’s family for being here.
“I would like to express my profound condolences to you.
“It was clear that Denise was a young lady with a lot to live for in life.”
If you need confidential support call the Samaritans on 116123 or visit a local Samaritans branch, see www.samaritans.org for details.
Young people can call Papyrus 0800 068 4141 or text 07786 209697.
For young people – Mind Your Way www.mindyourway.co.uk.
Outlook South West www.outlooksw.co.uk.
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