A CORONER says lessons must be learned after failings were identified following the death of a vulnerable woman who was let down by her health trust.

Now recommendations have been made following the inquest of Winchester University student advisor Louise Locke.

Her family have vowed to take legal action against Southern Health NHS Trust, which is already at the centre of a series of scandals.

That came following the release of a damning independent report condemning the Hampshire-based trust for failing to investigate the deaths of hundreds of people with mental health problems and learning difficulties.

Miss Locke, 44, was found hanged at her home in Milland Road, Highcliffe, on May 27 last year Winchester Coroner’s Court heard she suffered from mental health problems which included a history of bipolar disorder, depression and problems with alcohol.

The two-part inquest heard how her life problems spiralled in autumn 2014.

She was told by a psychiatrist that she did not suffer from bipolar disorder, and ruled her problems were mainly due to alcohol.

The inquest heard she sought a second opinion, and an appointment was made. However she was discharged from the Community Mental Health Team in Winchester on March 27, 2015, after she spoke of her difficulties about attending the appointment.

In the following two months her problems worsened and she attended A&E three times in April after self harming and drinking excessively, but no staff saw her as at risk or noticed a pattern to raise the alarm.

The inquest heard how a day before her death, a referral was received from emergency services to the mental health out of hours liaison services.

It heard how Miss Locke said she had suicidal thoughts and said she wanted to be admitted to hospital but her pleas were refused – a day later she was found dead by her estranged partner Chris Rostron.

Bosses at Southern Health admitted there were key failings.

Giving evidence, area head of nursing and quality, Carol Adcock, confirmed Miss Locke’s care co-ordinator was insufficiently trained and said he was overwhelmed by the workload.

Ms Adcock stated that staff should have raised the alarm several times, but no-one took responsibility and added more should have been done to help Miss Locke attend the appointment.

She added risk assessments should have been noted on the healthcare computer system, when a risk event happens and a ‘multi-disciplinary discussion’ about Miss Locke should have happened.

Since Miss Locke’s death, 14 ‘learning points’ have been made by the trust, the hearing was told.

Senior Coroner Grahame Short recorded the death as a suicide and confirmed he would be write to Southern Health to request a prevention of future deaths report.

The family of Miss Locke have confirmed they will be suing Southern Health.

Her daughter, Christie Maguire, said: “We are shocked and disappointed to hear that there were so many missed opportunities by several agencies to keep mum safe from harm.

“We genuinely hope that lessons will be learnt from this investigation and that any recommendations for improvement will positively impact the care that other mental health patients receive.”

In a statement Dr Lesley Stevens, medical director at Southern Health said: “We were deeply saddened to learn of the death of Ms Locke, who had been known to our services for a number of years.

“We recognise a number of things could have been done differently and regret that the level of service Ms Locke received during the last year of her life did not always meet the high standards we expect. We wish to extend our sincerest condolences to the family at this difficult time.

“We have already undertaken a number of actions to improve our services and ensure that tragedies such as this do not happen again. This includes implementing a standard screening process across all Community Mental Health Teams so that no one person is left to make a decision on their own.

“Our Acute Mental Health Team in Winchester has already put in place a process to identify people who attended the Emergency Department three times in a single month with mental health problems and we plan to roll this process out across all our Adult Mental Health Team services across Hampshire.

“As part of the Crisis Care Concordat, which aims to improve the system of care and support for people in crisis who have a mental health condition, Southern Health are working closely with a range of agencies. This includes the police, local authority, Emergency Departments and the ambulance service to develop High Intensity User Groups across Hampshire. We anticipate that the implementation of these groups will enable us to form a more holistic picture, which will better inform the care and treatment for people in crisis.

“We support the Coroner’s recommendations to implement the actions we have identified and have already begun to put these in place across the county. We believe this will have a positive impact in community mental health care and help prevent tragedies like this from occurring again.”

Moore Blatch partner, Vicky Hydon (left) with Christie Maguire, daughter of Louise Locke.

SOUTHERN Health NHS Foundation Trust is accused of “serious failings” in a scathing report revealing that it failed to investigate the deaths of hundreds of people with mental health problems and learning difficulties.

The inquiry revealed that of the 10,306 deaths between April, 2011 and March, 2015, 722 were categorised as unexpected and only 272 had been investigated.

The report was commissioned by NHS England, carried out by Mazars, looked at deaths of people who had been in contact with the organisation at least one year previously.

It was called for following the death of Connor Sparrowhawk, 18, who drowned in a bath after an epileptic seizure at Slade House, in Headington, Oxfordshire in 2013.

At his inquest a jury concluded there were “serious failings” in his bathing arrangements.

Inspectors from the Care Quality Commission (CQC) have now launched a “focussed inspection” at the trust - following previous inspections in October 2014 and August last year.

They are scrutinising improvements being made in reporting of deaths and check on developments being made to the trust’s learning disability and forensic services following the previous reports.

A former trust health and safety practitioner Mike Holder claimed he flagged up serious concerns four years ago when he warned of “dysfunctional” management systems and “haphazard” record-keeping.