Mentally ill woman starved to death
from various sources – November 2018
submitted by – Tippa Naphtali
news updates will be listed at the foot of this item
Ruth Mitchell was 40 when she was found lying on bare floorboards, starved to death, with only the clothes on her back in her St Budeaux home in 2012, prompting a series of reports which found multiple failings in her care.
She was under the care of mental health services at the time. The level of care she was receiving had been reduced from Enhanced Care Programme Approach to standard care in 2007-08.
This meant nobody visited her at home any more. When she died, she had barely any possessions or furniture and had lived without heating or hot water for four years.
Police dealt with three incidents with Ruth in the first half of 2007. In June, her parents made a complaint to health services and asked for the level of care to be enhanced and more focused. Following a review, mental health services reportedly decided to discharge Ruth from the Enhanced Care Plan and stepped her down to standard care despite concerns from her consultant psychiatrist.
Ruth’s parents describe that decision as “perverse”, saying it led to her increasing isolation, self-neglect and her eventual death.
A 2017 report reviewing Ruth’s case found there were failings in her care. She had been without hot water and heating for four years. She was last seen by a mental health professional eight months before. The report says there was no sense of Ruth “as a person” and that in her case, “agencies worked very separately and shared no information”.
The report continues: “Building up a picture of a person who is self-neglecting and devising a plan to support them, is dependent on agencies being aware of their own and other agencies’ responsibilities and sharing information. After Ruth was identified as self-neglecting in December 2010, or later in 2011, no enquiries were made of external agencies by mental health services, no framework for information sharing was put in place.”
The report recommendations include:
- Better information sharing between agencies to prevent harm
- Agencies must assure the Plymouth Safeguarding Adults Board that they are implementing the multi-agency adult safeguarding risk management, self-neglect and hoarding policy
- Training should be given across agencies in relationship-based approaches to people who self-neglect.
- Contacts must be circulated in each agency as key links in self-neglect
- Agencies must risk assess and draw up plans to mitigate the risk of service quality diminishing during times of organisational change and these plans must be shared with the Safeguarding Adults Board prior to organisational change, for the purpose of scrutiny
- NHS England, Clinical Commissioning Group, public health and local authority commissioners must work with primary care services, public health and Livewell South West to consider how the physical, as well as mental, well-being of people with severe mental ill health is supported
- Livewell South West must ensure that community mental health teams are informed by adult social care workers and that adult social care staff are included in multi-disciplinary meetings, to enable perspectives from staff who may be more experienced in working with adults who self-neglect
Following the publication of the report, Ruth’s parents, Russell and Anne Mitchell , said there was a case for corporate manslaughter and asked Devon and Cornwall Police to investigate.
Mr Mitchell, a retired chief superintendent with Devon and Cornwall Police and the chairman of Plymouth Hospitals NHS Trust for four years from 1997 to 2001, said: “The fact that Devon and Cornwall Police are to investigate the circumstances of our daughter’s avoidable death whilst under treatment by Livewell South West is welcomed. We see it as a natural next step arising from the independent inquiries conducted so far, which whilst examining why things went so tragically wrong for Ruth, did not address issues of culpability.
“We accept medicine is not an exact science, but these circumstances are not about a misdiagnosis, it is more akin to clinicians and the corporate entity making a wilful decision not to follow accepted clinical practice and agreed local policy, and as a result Ruth suffered.
“Devon and Cornwall Police will hopefully investigate this matter thoroughly and bearing in mind the significant public interest involved here, we are hopeful that the police will liaise with the coroner to review the original inquest evidence and take into account everything that has since been revealed and which the coroner was unaware of at the time and therefore unable to examine.
“A second inquest would allow all the evidence to be formally entered into the record and ensure a verdict is arrived at which accurately reflects the circumstances and factors contributing to Ruth’s avoidable death.
“This of course would be subject to the outcome of the police investigation and any criminal proceedings the police may consider proffering.”
How Plymouth woman Ruth Mitchell was allowed to starve to death
2 November 2017