MORE could have been done to protect a young woman who took her own life after being ‘rushed’ into living partly on her own – a safeguarding review has found.

The woman from Berkshire, known only as Michelle, battled depression and paranoid schizophrenia for a number of years before taking her own life in 2019.

Michelle, who had a troubled upbringing, was under the care of a number of local care providers at the time which have since been asked to improve for their level of support.

The review  – carried out when a person in care dies – describes how Michelle, who lived in either Reading, West Berkshire or Wokingham, had grown up with her ‘loving’ paternal grandparents from the age of two.

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She was unable to live with her mother, who had long-standing mental ill-health, and her father, who was an alcoholic, while her maternal grandparents both had been admitted to psychiatric hospitals.

Diagnosed with depression and paranoid schizophrenia in 2015, she was voluntarily admitted to an Adolescent Mental Health Unit in January 2017. Her grandparents felt unable to continue caring for Michelle, feeling they could no longer offer the support and supervision she needed.

She was moved into semi-independent accommodation by children’s social care in July 2017.

The review said Michelle had mixed views about the move, as the other tenants had learning disabilities and she felt very different to them.

Despite social workers suggesting she appeared to have settled in well, Michelle’s birth father said she did not like being at the accommodation, was being ‘pestered’ by older tenants, and was upset because ‘staff did nothing’ to help.

Michelle initially had 56 hours per week of support, including a staff member ‘sleeping in’ at Michelle’s flat in the spare bedroom to ease her anxiety of being alone, but this was reduced to 35 hours at age 18.

During her time in this accommodation, Michelle went missing twice, went between having suicidal thoughts to feeling stable, and was confronted about her use of cannabis.

Four days before her death, Michelle’s father said she had been happy but a little ‘quiet’ but carers found her just days before this ‘crying and not feeling herself’.

On February 18, 2019, Michelle refused to open her door and when staff entered she was found ‘quiet, snivelling and muttering’ but willingly took her medication.

She was seen that afternoon heading back to her room, in which she locked herself inside and didn’t engage with any staff.

The review describes how a sleep-in staff member heard Michelle that night watching television at 1am, but on that morning of February 19 Michelle would again not answer the door.

Family members agreed to leave her alone, but by 3pm all concerned parties agreed to call the police.

Officers forced their way into the flat at 4.40pm and Michelle was found on her bed having taken her own life.

Her personal advisor later found she had posted a picture of a coffin a few days earlier on her Facebook.

The care providers supporting Michelle have been criticised in a recent Safeguarding Adults Review, published by the Berkshire West Safeguarding Adults Board.

Safeguarding adult reviews are conducted when an adult in care dies as a result of known or suspected abuse or neglect, and where there is concern care providers could have done more to protect an individual.

The authority ruled that more effective working could have helped protect the young woman, as well as additional support to help her transition into semi-independent accommodation.

It said the ‘rushed’ move into self-independent accommodation was “misplaced” and did not consider her lack of ability to fully care for herself, her vulnerabilities or the impact of her mental ill-health. It also said the level of monitoring once moved in was ‘poor’ and her care provide lacked formal mental health training.

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The review ruled that alternative options should have been considered to help the move from living with her grandparents.

It added: “Whilst she received care from her wider family, she remained a vulnerable young woman who had mental ill-health for several years.”

It also described how Michelle’s vulnerability was sometimes ‘overlooked’ because of her positive presentation and outlook.

The care providers involved will now have to make changes to ensure:

  • Young people with mental health needs leaving care are well-supported post-18
  • Internal doors allow appropriate access to staff members whilst maintaining confidentiality and personal space
  • Escalation processes are robust
  • Appropriate training is in place
  • Placements are appropriate

When life is difficult, Samaritans are here – day or night, 365 days a year.

You can call them for free on 116 123, email them at jo@samaritans.org, or visit www.samaritans.org to find your nearest branch.