Suicidal student nurse, 23, took fatal overdose

Suicidal mental health nurse, 23, took fatal overdose believing her death would ‘save mankind of its sins’ after NHS call handler failed to note her name so never organised visit from counsellor

• Melody Vazquez, 23, who had bipolar disorder, was found dead in a field
• Had previously tried to kill herself by eating poisonous berries and stabbing 
• Her psychotherapist had asked the home treatment team to contact her
• But call handler failed to write down the name, so the visit was never made

Melody Vazquez, who had bipolar disorder, was found dead in a field in Berkshire

An student mental health nurse took a fatal overdose believing her death would ‘save mankind from their sins’ following a psychiatric crisis, an inquest has heard.

Melody Vazquez, 23, who had bipolar disorder, was found dead in a field in Finchampstead, the Berkshire village where she lived with her mother. 

She had previously tried to kill herself by eating poisonous berries and stabbing herself, the inquest in Reading was told.

Miss Vazquez told a consultant psychiatrist she was seeing signs that affirmed her belief she needed to end her life ‘to bring peace to the world’ and insisted she attempted to end her life to ‘save mankind from their sins.’

She was sent home from hospital after receiving psychiatric help, without any plan to monitor her condition or a counsellor to check on her progress.

Her psychotherapist, Kay Longworth, had been so concerned about Miss Vazquez that she had asked the home treatment team to contact her, the inquest heard.

Miss Vazquez (pictured) told a consultant psychiatrist she was seeing signs that affirmed her belief she needed to end her life ‘to bring peace to the world’

However, a call handler had failed to write down the name during a phone call, so the visit was never made. Her body was found by a passer-by on April 12 last year.

Speaking outside the inquest, her former boyfriend Adam Wilson criticised Berkshire Healthcare NHS Foundation Trust for the lack of care she received before her death.

He said: ‘The opportunity to have averted this was with post discharge care – there is no discharge care, they were playing catch-up and expecting it to work. 

‘I think the way that the trust handles this sort of thing is primarily focused on absolving themselves from responsibility. She’s dead and she shouldn’t be.’

Mr Wilson, who met Miss Vazquez while at Prospect Park Hospital in Reading, added: ‘What happened to her is really not unusual.’

The Berkshire Coroner, Heidi Connor, also criticised the trust in a letter which was revealed via a Freedom of Information request today.

In this, she expressed concerns about how Miss Vazquez’s care co-ordinator was on sick leave during the month after Miss Vazquez was discharged in January last year.

Concerns were also raised over how Miss Vazquez was given no other care co-ordinator because she was not deemed to be especially at risk.

Mrs Connor wrote: ‘Evidence revealed that from around March 2018, Melody’s care co-ordinator (Becky Price) was away from work on sick leave for around a month.

‘I was told in evidence that Ms Price’s case load was reviewed by her team leader and it was felt that a substitute care co-ordinatior was not required because Melody was being seen by a psychotherapist (Ms Longworth). 

‘In fact it would seem from ms Longworth’s statement that she was due to see Melody for four sessions, the fourth of which took place on April 11, 2018. 

‘Tragically that was the date on which Melody went missing, she was found the next day having taken an overdose.

‘I heard no evidence about a plan in place to review the question of whether Melody required a care co-ordination. This was perhaps even more significant given that Ms Longworth’s involvement with Melody was due to come to an end. 

‘Staff were clearly concerned about Melody at that time and they requested Crisis Resolution and Home Treatment Team (CRHTT) to speak to her. 

‘Given the chronology in this case I did not find that this played a part in causing Melody’s death but I am concerned that this could make a difference for other patients.’

Giving evidence at the inquest, Ms Longworth said the CRHTT had never spoken to Miss Vazquez because a member of the crisis team had failed to log her name.

The coroner had said: ‘So, it wasn’t that the crisis team was too busy or under-staffed, they just didn’t note down which patient it was? Is it as simple as that?’

Ms Longworth had told the inquest time pressures at the crisis team were common, but the coroner said: ‘The bottom line is that this person had the time to take the call but never wrote it down. So it seems slightly more than being too busy.’

In a response to the coroner, also revealed by an FOI request, Dr Minoo Irani, medical director at the Berkshire NHS Trust, said: ‘Thank you for raising your concern about procedures in the trust for managing care coordinator sick leave, following the hearing of the inquest of Melody Vazquez.

‘I agree that deficiency in this aspect of our service could have implications, in general, for the quality and safety of patient care in community based mental health services in Berkshire Healthcare.

‘Care coordinator sick leave is currently managed by each of the locality based services through their local procedures rather than through one consistent trust policy or Standard Operating Procedure (SOP).

‘To ensure that all localities have a consistent approach and to take into account the concerns that you have raised, Debbie Fulton (Director of Nursing and Governance) and I requested our Clinical Director for Mental Health Services to review the local procedures in place and prepare a SOP which could be implemented trust-wide across all our community Mental Health Services.

‘We are committed to improving systems and processes within the trust, to ensure safe care for our patients.’ 

For confidential support in the UK call the Samaritans on 116123, visit a local Samaritans branch or click here for details   

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