https://www.dailymail.co.uk/news/article-11654519/Mental-health-blogger-took-life-taking-poison-bought-online-Russia-inquest-finds.htmlMental health blogger, 26, who took her own life after taking poison she bought online from Russia while in hospital was neglected by the psychiatric unit treating her, inquest finds
Beth Matthews was neglected by staff at the Priory Hospital Cheadle Royal
An inquest heard the 26-year-old collapsed in front of staff on March 21, 2022
It was later found she had taken a toxic substance purchased online from Russia
The court was told if her care plan was followed, she would not have ingested it
By Matthew Lodge For Mailonline and Ian Leonard
Published: 18:03, 19 January 2023 | Updated: 18:05, 19 January 2023
A mental health blogger who took her own life after ingesting poison she had bought online from Russia was neglected by the psychiatric unit treating her, an inquest has found. Beth Matthews had been categorised as being at 'high risk' of suicide when she had the substance shipped to her on a psychiatric ward at the Priory Hospital, in Cheadle Royal, near Stockport. The 26-year-old was being surpervised by two members of staff on March 21, 2022, when she opened a parcel containing a plastic bottle of the substance, despite orders she should not be allowed to open her own mail. She initially told staff it was 'protein powder' before ingesting it in front of them despite their efforts to stop her, after which she told them 'I'll be dead in an hour'.
Ms Matthews suffered a fatal cardiac arrest the same day. A nine-day inquest found that 'neglect' by staff had contributed to her death, with The Priory Group admitting her care plan 'was not followed' and if it had she would likely 'not have ingested the substance, and would not have died as she did'.
The hearing was told the upcoming three-year of her previous suicide attempt, as well as a recent break-up with her long-term partner Matthew Parkinson, the possibility of being transferred back to Cornwall, and a looming tribunal to challenge her section, were all factors likely to have had a 'negative' impact on her mental health in the lead-up to her death. Analysis of her mobile phone showed during her time at The Priory, Beth made 'frequent' internet searches relating to the substance she ingested, especially during the two-week period prior to her death, the Manchester Evening News reports. She also accessed online forums discussing suicide, and told a mental health nurse just weeks before her death that 'there are things you can purchase that can do the job'.
When pressed, Beth told the carer 'it's already done now,' and refused to expand further on her comment.
Beth's consultant at The Priory said this should have been raised with him but that she was on the highest risk level at the hospital already and as a result should not have been opening her own mail. A handover document completed by night shift staff for the day team stated: 'Staff must open parcels for EM [Elizabeth Matthews]. Risk of secreting items from parcels'.
Her care plan also contained a 'clear' instruction that she shouldn't be allowed to open her own mail, the jury heard. Delivering a verdict of suicide contributed by neglect, the jury said it was evident 'serious inconsistencies' existed 'across all levels of management' at the hospital in relation to knowledge of Ms Matthews' care plan. The jury noted a lack of communication, a failure to escalate serous risks practices, lack of team cohesion, reliance on inadequate and inaccurate information, in particular to post management. 'Evidence provided demonstrated frequent deviation from Priory policy and care plan guidance which contributed to an increase risk to Elizabeth Matthews,' they said.
The management of Ms Matthews' post was clearly outlined in her care plan and handover notes, they said, but staff had 'consistently failed' to recognise post management as a 'serious risk', resulting in 'inadequate care of a highly vulnerable patient'.
There was also 'failure' to escalate a conversation Ms Matthews had with a member staff about buying items to end her life, the jury said, so the clinical team could review her risk management. The inquest heard from healthcare assistant Olivia Woodruff, designated 'security' for distributing mail to patients that day and one of those who tried to restrain Ms Matthews, who said she hadn't seen the handover document and 'nothing' was mentioned to her verbally. She admitted to never having opened parcels with Ms Matthews before and 'didn't know' the correct procedure. Ms Woodruff checked with ward manager Jonathan Heathcote who told her that Ms Matthews was a 'Level 2' patient meaning she could only open parcels in front of two staff stood at arms' length. Less than three weeks before her death Ms Matthews discussed ending her own life with nurse Leanne Williamson and purchasing something 'that can do the job'.
But Ms Williamson did not escalate any risk concerns because she believed Ms Matthews would be 'safe' due to her care plan and she'd 'got used' to her conversations about death. NHS patient Ms Matthews had been sectioned under the mental health and was transferred to the hospital's Fern Unit for specialist therapy in November 2021. She carried out frequent internet searches relating the substance and had accessed a suicide website, which discussed methods and contained discussion threads about its use. David Watts, director of risk and safety for the Priory Group which ran the hospital, told the inquest that warnings about the substance were given in staff bulletins in 2018 and 2020. Suzanne Barnard, a former hospital director who investigated the tragedy, said there was an 'inconsistent approach' to the delivery of Ms Matthews' care plan - with some staff opening post for her and others allowing her to do it herself. But the jury was told that police had ruled out any criminal charges over her death. Ms Matthews, from the village of Menheniot near Liskeard in Cornwall, suffered mental health from an early age and was diagnosed with an emotionally unstable personality disorder (EUPD) Following a failed suicide attempt in 2019, which left her with life-changing injuries, she acquired a large social media following by sharing her experiences on the blog Life Beyond the Ledge. She was also an accomplished yachtswoman, completing the Fastet race at the age of 15, and she described by her mother Jane Matthews as 'bright and vivacious' and 'highly intelligent with a quick sense of humour'.
Assistant coroner Andrew Bridgman passed on his condolences to Ms Matthew's family and noted that the hospital had since had made changes to its procedures since her death. Her family said in a statement: 'We would like to thank the coroner, jury and our legal representatives Leigh Day for their diligence in ensuring there was a thorough investigation into Beth's death. The passing of Beth that day was wholly avoidable and her death was completely unnecessary. We have been tragically let down by the Priory, who we believed were providing a safe place for Beth and the care that she needed.'
They added: 'Beth tried to help others through describing her own mental health experiences in a highly graphic but articulate way and by doing so was able to touch and help countless others. We know for a fact that she saved at least one person through her social media presence. That is a huge legacy for a young lady to leave behind. Beth gave a bright light of hope to people who were struggling to see any light at all. May she now rest in peace.'
The family's solicitor, Leigh Day clinical negligence partner Stephen Jones, said: 'This was a particularly upsetting inquest. Beth's death came about because a very simple and straightforward instruction in her care plan, that staff should open parcels for her, was not followed. Had the care plan been followed, Beth would not have died. We hope that the jury's finding that Beth's death was contributed to by neglect will help shine a light on what happened and emphasise the need for improvements to be made.'
A spokesperson for the hospital: 'We want to extend our deepest condolences to Beth's family and friends for their loss. Beth's attempts to overcome her mental health challenges had been an inspiration for many. Although unexpected deaths are extremely rare, we recognise that every loss of life in our care is a tragedy. We fully accept the jury's findings and acknowledge that far greater attention should have been given to Beth's care plan. At the time of Beth's unexpected death, we took immediate steps to address the issues around how we document risk and communicate patients' care plans, alongside our processes for receiving and opening post. Patient safety is our utmost priority and we will now review the Coroner's comments in detail and make all necessary, additional changes to our policies and procedures.'
