Better mental health care
Chris Tasker says he is satisfied with the conclusion of Rachel’s inquest the house for four years and shut out the people she loved the most.
Mr Tasker said: “Rachel did love people but she found it difficult to relate to others and I know she was frustrated by that.”
It was only later in her life that she was diagnosed with an autism spectrum disorder.
During the inquest into the circumstances surrounding Ms Tasker’s death at Newcastle Coroner’s Court, a number of “inadequate” features about her care were identified.
The “care plan” drawn up by SLAM
doctors for her temporary stay in Newcastle “did not identify any support for her while on leave or contingency plans should the leave break down or should Rachel refuse to return from leave”, the inquest heard.
Coroner Karen Dilks also singled out SLAM’s failure to agree the care plan with mental health specialists in the North East as another crucial shortcoming.
After Ms Tasker’s overdose on September 22, her mum informed hospital staff in London – but the inquest found this new information “did not trigger any formal review of her care plan” and it wasn’t even officially recorded until five days after the event.
During that crucial period between her first overdose and going missing, the only substantial communication between London and North East health professionals was a letter from a junior doctor which was found during the inquest to have “lacked force”.
Giving evidence, one SLAM doctor said they were “expecting” more information from NHS staff in the North East but nothing came.
The coroner repeatedly questioned if their failure to be more proactive in obtaining that information amounted to a failure in their duty of care.
Formally concluding the inquest, the coroner said: “Rachel took her own life while suffering from mental illness and in part because the risk of her doing was not recognised.”
She added that “appropriate action had not been taken to minimise the risk” of a suicide attempt following her first overdose.
Speaking after the inquest and fighting back tears, Mr Tasker said: “The process has taken two years and it impacts on the whole family, her two sisters, her grandparents.
“But the conclusion we’ve heard today is what we wanted.”
Mr Tasker said they obtained a note written months before his daughter’s death, which made it clear she knew something had gone wrong.
He said: “We know Rachel did not want other people to go through what she had from writings on her computer we found after her death.
“She wrote these notes at hospital during a low point when she didn’t want to be on the ward anymore.
“But when I read it I knew she was talking about more than that, she was talking about all the years she had suffered when she just wanted to have a normal life.
“As a parent, it’s heartbreaking, but reading that as a doctor you think something must change at a practical level.”
Both SLAM and the Northumberland, Tyne and Wear NHS Foundation Trust were told by the coroner they must improve.
Mrs Dilks said: “I’m not convinced that the information that’s been provided in respect of SLAM is sufficient to persuade me that another incident like this would not occur.”
Both trusts have said they are implementing changes to make sure vulnerable people don’t get lost in the gap, which is created when two parts of the NHS fail to talk to each other.
Gary O’Hare, executive director of nursing and chief operating officer at Northumberland, Tyne and Wear NHS Foundation Trust, said: “We appreciate how challenging this has been for Rachel’s family during this difficult time.
“We have conducted a detailed review and have made changes to our practice and policy to improve the way we communicate.
“We will now reflect on the conclusions drawn at the inquest.”
A spokesperson for South London and Maudsley NHS Foundation Trust said: “We offer our sincere condolences to the family and friends of Miss Rachel Tasker at this difficult time.
“Following Rachel’s death a full internal trust investigation was carried out and lessons have been learned to ensure we make the changes which reduce the possibility of this ever happening again.
“We recognise that in Rachel’s case there were failings in essential communication and information sharing.
“We have amended trust policy to incorporate guidance on managing incidents and risks which occur when a patient is away from the ward and we will be reviewing these policies further in light of the Coroner’s findings.”