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29
Nov
Warning: this story contains mentions of suicide. If you are struggling with your mental health, please contact a professional. You can call Samaritans for free on 116 123, email jo@samaritans.org, or visit samaritans.org to find your nearest branch.
Harrogate woman Sophie Lambert heard a mental health worker describe her as a nuisance, an inquest yesterday heard.
Ms Lambert's body was found in the River Nidd on June 21, 2023, five days after she left home in Starbeck.
Hundreds of people joined the missing person search, which also included police helicopters, drones and dogs. It was supported by mountain and underwater rescue teams.
Area coroner Catherine Cundy told the court Sophie was described as honest, musical and an animal lover. But her mental health conditions, including complex post-traumatic stress disorder and emotionally unstable personality disorder, became difficult to manage.
Ms Cundy said Sophie was “traumatised” by an incident, after which she was repeatedly admitted to hospital for her mental health.
The inquest heard Sophie’s mum, Michelle Robinson, was her daughter’s “support and carer”.
Ms Robinson said both she and Sophie felt “let down” by the community mental health service after one particular incident.
She said:
Sophie had called the children and adolescent mental health services (CAMHS), and the team member obviously hadn’t disconnected the call. Sophie heard the woman call her a 'f****** nuisance'. She lost trust in them.
Ms Robinson also told the court she was never made aware of Sophie’s diagnoses.
“Had I been involved I would have been able to seek help on how I could deal with her", she said.
Police searching for Sophie Lambert.
The inquest heard Sophie was admitted to hospital for her mental health around 30 times in her life, both as a child and an adult.
Mr Houghton, a nurse consultant at Foss Park Hospital in York – which is part of the Tees, Esk and Wear Valleys NHS Foundation Trust – told the hearing Sophie struggled to engage with staff and would consistently say she just wanted to be at home with her mum.
He said she needed proper trauma therapy, but this could not be provided in-house as it is delivered through the community mental health services.
"We just wanted Sophie to know people were there for her", Mr Houghton added.
Sophie's last admission before her death was at Cross Lane Hospital in Scarborough, which is also part of Tees, Esk and Wear Valleys NHS Foundation Trust.
Dr Bassey, who was part of the mental health team that looked after Sophie, told the inquest Sophie fed chickens in the hospital grounds with other healthcare workers, and responded better to them than the mental health team.
He told the inquest:
Sophie worked with a psychotherapist. She tried to engae with and get to know Sophie, but she felt as though she wasn’t getting anywhere.
It was really difficult to get Sophie to trust us.
Dr Bassey also said Sophie did not want to engage in long-term care with the community mental health teams after discharge, as she did not trust people.
Despite telling staff she wanted to leave the hospital, Dr Bassey said Sophie became very distressed around the point of discharge.
Sophie felt the hospital was “rejecting her” by discharging her, Dr Bassey said.
Sophie Rebecca Inez Lambert
Tees, Esk and Wear Valleys NHS Foundation Trust carried out a patient safety investigation after Sophie's death.
Jemma Hill, associate director of nursing at the trust, told the court there should have been more contact with Sophie’s mum.
The court heard Sophie did not answer calls from the mental health services and Ms Hill recognised more action should have been taken to liaise with Ms Robinson instead.
Ms Hill said the trust has since introduced a new records systems, which has improved internal correspondence between staff. The new system also confirms if a person – like Sophie’s mum – should be made aware of any updates with a patient.
CCTV showed Sophie leaving her house on June 16 after posting her keys through a letterbox.
At midnight on June 17, Sophie called a family member. The court heard she was "incoherent" during the call. This was the last contact the family had with Sophie.
After a five-day search, a dog walker saw Sophie’s body in the River Nidd near Knaresborough on June 21.
Emergency services were called, and Sophie was certified dead at 10.26am.
A toxicology report found Sophie had traces of a drug in her system at a level associated with fatality, but her preliminary cause of death was found to be drowning.
Ms Cundy said the trust had taken steps to prevent recurrence. She noted it is difficult to offer “meaningful treatment” to a patient who does not want to engage.
The coroner added the trust could have sought alternate strategies of trauma therapy. However, Ms Cundy said she was not able to conclude this would have changed the outcome.
She also said there were “unacceptably poor encounters” between the mental health services and Sophie and her mum.
Sophie’s death was ruled a suicide.
The Stray Ferret approached Tees, Esk and Wear Valleys NHS Foundation Trust about the inquest findings.
Beverley Murphy, chief nurse at the trust, said:
Our thoughts are with Sophie’s family during this difficult time. We are truly sorry for their loss.
We will act on the inquest findings and continue to improve so that we can provide the best care possible. We welcome the opportunity to meet with Sophie’s family and answer any questions they may have.
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