A student battling mental ill-health took her own life following 'missed opportunities' by an NHS trust to help her, a coroner has concluded. Kate McBean - who struggled as a coursework deadline loomed, finding herself in a 'situation of despair' - was found dead at her student accommodation in Withington, south Manchester, on August 20, 2019.
Kate's time in Manchester started well, her tutors said. But by around November 2018, her attendance started dipping. As Kate's mental health deteriorated, she fell behind with her studies. Assistant coroner Andrew Bridgman identified a 'gap in the evidence' - until April - following Kate's February referrals. On April 10, the court heard Kate was admitted to A&E at Manchester Royal Infirmary after attempting to take an overdose.
On May 22, a meeting within the community mental health team was held and Kate's case was reviewed. That followed her overdose attempt and after university bosses said she was too 'high risk' for their staff. 'Stress' as coursework deadline loomed In July, concerns were raised by Kate's friends about leaving her alone. She had continued to fall behind with her studies, with lecturers giving her extensions to finish projects by August 19. She did not want to defer or take a year out, the court heard.
Another referral was made on August 13 to GMMH, but Kate didn't attend an appointment. A further assessment was requested, with orders for Mental Health Act provisions to be considered, but that was not done. "At the time, the care plan would have been to wait for a mental health assessment and the service would have taken the decision," she added. The home-based team couldn't 'insist' on that at the time, she said, but that policy has since been altered.
Evidence of drugs and a poisonous chemical were found in the room. Pathologist Dr Moshi Mazhari told the court Kate's cause of death was 'unascertained' as there were no injuries or evidence of significant drug or alcohol use in her system. Mr Bridgman highlighted Ms Byrne's evidence surrounding a 'lack of persuasiveness' in rearranging appointments - and the fact staff 'simply accepted' her self-discharge on August 5. That 'shouldn't have been done without a further review', he said, adding: "This was a missed opportunity by the mental health authority."