Coroner says TEWV failures contributed to Linda Banks death

Staff ‘underestimated’ the risk Linda Banks posed to herself and overlooked her distress and paranoia, viewing them as not ‘genuine’, the coroner said.

In the months before her death from an overdose on April 10, 2022, Linda, 48, had been a patient of the County Durham and Darlington Crisis Team, part of the Tees, Esk and Wear Valleys (TEWV) NHS Foundation Trust.

Concluding an inquest this week Assistant Coroner for Durham Ms Janine Richards said Linda “did not receive the right care at the right time” and that TEWV's “actions and omissions” contributed to her death.

Crook Coroners Court previously heard that Linda had been in touch with multiple TEWV services to ask for help with increasing distress, anxiety, low mood, suicidal thoughts, and paranoia.

Linda died after taking a fatal overdose. (Image: Family Handout)

Linda was struggling to look after herself and her home, not eating or drinking for long stretches, and had difficulty coping with her mother’s death, financial stress, and ending her use of alcohol. Before she died, she told police she had not eaten for seven days.

It emerged during the inquest she contacted the crisis team up to four times a day from February 2022 to her death that April.

But despite pleas for help, crisis team staff did not think she posed more than a “low risk” to herself and failed to refer her to specialist teams that could have helped.

At the time the crisis team was in ‘business continuity measures’ with many staff positions unfilled and the service struggling to cope with demand. Unregistered and unqualified practitioners took calls from people in crisis, the inquest heard.

The coroner said a recurring theme emerged in Ms Banks’ care where clinicians consistently overlooked her distress and paranoia, viewing them as not ‘genuine’.

It was also claimed staff told concerned family and friends to back off and give Linda space.

An inquest was held at Crook Coroners Court.

Linda’s brother, Jonathan Banks, told the inquest a mental health worker recommended they “give her space” and insinuated that she was “seeking attention,” prompting the family to “step back.”

Meanwhile her "best and oldest friend" Helen Cooke told the court that when she phoned mental health teams for help just days before Linda’s death she was told to give "tough love" as her friend was "putting it on."

The claims were disputed by the trust with counsel Emma Sutton KC saying it “simply did not happen”, but coroner Ms Richards said she was “entirely satisfied” that although exact details may be mistaken the general advice to step away was given. She branded it “wholly inappropriate”.

She said Linda’s family did back off and believed they would have only done so if they were following advice.

The family said Linda was the “kindest of people” who “worked hard” raising money for various mental health charities.

Linda was a patient of the Tees, Esk and Wear Valleys NHS Foundation Trust.

Her death came just five months after a thematic review undertaken by TEWV following the deaths of four patients in 2021 after contact with the crisis team.

That review identified eight areas of failure. Seven of which were still applicable at the time of Linda’s death.

Ms Richards concluded the actions taken by the trust after a thematic review were “ineffective” in preventing Ms Banks’ death, adding she “did not receive the right care at the right time”.

The trust maintains it continues to learn lessons and has made significant improvements.

Speaking after the inquest Jonathan Banks said: "Linda was always a busy person, and loved going to her awareness group and raising funds. Her house was always full of prizes for draws and tombolas - we said she always worked at least three tombolas ahead.

"Yet again the failings of the Durham and Darlington Crisis Team have been highlighted in the tragic death of my sister, Linda.

“A catalogue of errors were revealed by the much delayed review into her death which was after a thematic review following 4 earlier deaths and many of the serious issues from that earlier review remained at the time of Linda’s death.

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“It is absolutely no comfort to say the crisis team was no longer in special measures, it should never have been allowed to reach those depths and contributed to Linda’s tragic death.

"Linda was the kindest of people and worked hard raising money for charity. We are all still hurting from her death and feel very let down by the mental health trust."

The crisis team came out of continuity measures in June 2023. TEWV adopted new processes including a 24/7 listening service, peer workers undertaking home visits, and “happiness hubs” to support wellbeing.

Beverley Murphy, chief nurse at the trust, said: “Coroner hearings can be very difficult for a family, and Linda’s family have been in our thoughts throughout. We are truly sorry for their loss.

“We reviewed Linda’s care and listened closely to the concerns of her family. We identified areas to improve and have been working hard to make these changes.

“We will act on the inquest findings and remain committed to these improvements and providing the best care possible.”

Linda’s family has joined calls for a public inquiry into TEWV.

Nine weeks after Linda’s death, another crisis team patient, David Stevens, took his own life. An inquest into his death noted that the crisis team “missed opportunities” in his care, though it could not be concluded that these significantly contributed to his death.

The Echo revealed in October how 20 patients died within six months of contacting the crisis team in the 12 months since June 2022 when David Stevens died.

TEWV claimed it made “significant improvements” that June, but 20 patients died in the year since.

In the 16 months prior to the claimed improvements, 21 patients died. Lawyers representing bereaved families Alistair Smith and Lucy Wennington, from Watson Woodhouse, said the numbers suggested TEWV “doesn’t learn despite stating that things have changed”.