Coroner says woman who killed herself ‘may have lived’ if full care plan set up
Rosie Fender, died of a serious head injury after being hit by a train near Romsey, Hampshire, on February 3 2022.
A coroner has said that a 26-year-old woman who killed herself may still be alive if a “holistic treatment plan” had been provided for her.
Rosie Fender, died of a serious head injury after being hit by a train near Romsey, Hampshire, on February 3 2022.
Her mother, Louise, told the Winchester inquest that her daughter had a history of agoraphobia and compulsive behaviour, as well as insomnia.
She also said that her daughter had been groomed while at school by her IT teacher, Nicholas Haines, who started a relationship with her when he gave her guitar lessons at the age of 13.
He was prosecuted for this abuse, but Rosie went on to live with him from when she was 18 years old and periodically until her death, the inquest heard.
Ms Fender said that her daughter’s mental health worsened from April 2021 when her fear of germs mostly prevented her from leaving her home.
She said that she would speak to her for hours on FaceTime and her daughter would shower for up to eight hours at a time.
She told the inquest that she had “begged” on a daily basis for her daughter’s healthcare providers, Southern Health NHS Foundation Trust – which is now part of Hampshire and Isle of Wight Healthcare, to intervene as Rosie’s condition worsened.
Now coroner Rosamund Rhodes-Kemp has recorded a conclusion of suicide and criticised the care provided which she also said had been affected by the Covid-19 pandemic.
She said: “Rosie Fender had complex mental health issues and childhood trauma.
“She had no comprehensive care plan, care co-ordinator or diagnosis due to inadequate resources.
“Had a holistic treatment plan been put in place when she was assessed and discharged by the psychosis team including involvement of family and carer or even more support for her and her carer had been provided after her move to a new area, Rosie’s sad death may have been avoided.”
In a statement released after the hearing, Ms Fender said: “My beautiful, fun, caring daughter was the light of my life but her beautiful bright star was unnecessarily and tragically extinguished, leaving me with a constant pain in my heart.
“She was so grossly let down by the medical professionals I constantly begged to help her, and this magnifies the pain I perpetually feel. I can never forgive them for that.
“It’s not just my Rosie’s life they have taken, but mine too. Where there was once light, I can only see darkness. I wish I could hug her again, kiss her, dance, laugh and sing with her but those dreams will never be realised because of others’ failures to care for her. My world is hollow without my beloved daughter.”
Gimhani Eriyagolla, of Hodge Jones & Allen, representing the family, said: “This is one of the most tragic cases I have ever seen.
“A vulnerable young woman who desperately needed help was dismissed without adequate assessment by healthcare professionals and left without support over an extended period.
“Had she received the right help when it was asked for, it could have made a crucial difference.
“My client was in contact with professionals on a daily basis to try and get much needed help for Rosie but her pleas and warnings that Rosie was at risk went unheeded.
“While nothing will bring Rosie back, today’s outcome is at least recognition that she was failed by those who were meant to help her and provides some vindication for Rosie and her family.”
Dr Daniel Baylis, chief medical officer at Hampshire and Isle of Wight Healthcare NHS Foundation Trust, said: “We offer our deepest sympathies to Rosie’s family and friends and acknowledge the coroner’s findings.
“We recognise that there were aspects of Rosie’s care that did not meet the standards expected, and for that we are truly sorry.
“This case has led to important changes.
“We have shortened waiting times for care co-ordination, strengthened how teams hand over care, improved how key clinical information is shared, and are working more closely with local partners to better support people with complex mental health and substance use needs.
“We will fully consider any further recommendations from the coroner, alongside the immediate improvements we made following Rosie’s death, to continue improving our services.”
