A woman with complex mental health problems committed suicide after funding decision errors by a primary care trust and local authority saw her prematurely removed from a care home.
A narrative verdict from a north London coroners court into the death of Sheila McInulty found “failures at every level of the process” between NHS Barnet and Harrow Council.
The verdict recorded by coroner Andrew Walker said: “In a performance review in July 2010 Mrs McInulty was identified as one of two patients whose care was over budget and the senior commissioning manager for NHS Barnet suggested that were they to be discharged early it would have a significant benefit on performance.”
As part of her treatment the 63-year-old had been in a residential care home, and after three months was subject to a routine funding review.
This concluded her needs were primarily for social care in her own home.
The coroner’s verdict said: “The two care workers present did not understand the process and believed that this was the start of a process. The conclusion was not formed by the opinion of the psychiatrist who had recommended that an extended period of rehabilitation before she could return home.”
He added that no support documents were gathered, a decision tool document was “lost and the assessment not repeated”, “there was no panel meeting to verify the funding decision” and Mrs McInulty was not told the decision could be appealed.
The NHS Barnet senior commissioning manager was incorrectly told that all were in agreement with the assessment and did not order the review be repeated, the court heard.
A date was agreed to transfer funding from NHS Barnet to Harrow Council who began the process of moving her home, despite a psychiatrist raising concerns about a potential overdose.
The verdict said: “These concerns were conveyed to the local authority commissioning manager who made a fundamental mistake about whether the residential care home could be funded by the local authority and did not take steps that could easily have been taken, to correct that mistake.”
Mrs McInulty, who had worked in the lost property office of cab firm Addison Lee, was given two days’ notice that she would be leaving the care home.
After returning home she did not attend appointments with her outpatient psychiatrist or GP and died from an overdose a few months later.
Coroner Andrew Walker concluded her death “was directly caused by the interruption of the agreed rehabilitation programme designed to allow Mrs Mcinulty to return home gradually”.
The inquest was held in April, and the verdict has since been released to HSJ.
Harrow Council, Central and North West London Foundation Trust, which commissions residential care placements on their behalf, and NHS Barnet, have all subsequently reviewed their procedures.