Tragic Victoria let down by system

FAILINGS in mental health referrals surrounding the death of a young Failsworth woman have prompted changes at the Pennine Care Trust.

Victoria Kershaw was found hanged at her home in Alan Avenue on January 24, days before her 24th birthday.

An inquest held and adjourned in May heard how Victoria was seen by A&E liaison nurse Laura McManus last December after taking a paracetamol overdose.

Ms McManus wrote a letter to Miss Kershaw’s GP recommending she be put on antidepressants — but the letter wasn’t sent until January 7.

A letter referring Miss Kershaw for an assessment was finally received by her parents on January 27 — three days after her death.

The inquest was originally adjourned to allow the Trust, which runs mental health services in Oldham, to explain the delay.

Speaking at the resumption of the case on Friday, Clair Carson, acute services manager for Oldham Mental Health Services, said the delay had been caused by a lack of dedicated administration support.

As a result, the Trust now sends faxes after assessments, followed by a letter.

She said: “It is accepted at the time this was not in place, hence the delay.”

She also said Miss Kershaw had had contact with the initial assessment team in October, 2008, but another administration error meant her details were not properly passed on.

The Trust was now reviewing the initial assessment and intervention service team, its administration systems and those of the community team. A new operational policy for the service is now in place.

Coroner Simon Nelson recorded a verdict that Victoria Kershaw took her own life while suffering from a stress-related disorder. Mr Nelson said he expected a copy of the Trust policy within 28 days. He said he would closely monitor whether guidelines and practice was being adhered to, and he would pick up on any shortfalls.

He added that it would be “inappropriate” and “unjustified” to draw a link between the delays and the provision of the care Victoria received.

He said: “Her full assessment that she received was in my view absolutely appropriate and demonstrated a high degree of professionalism on behalf of Ms McManus.

“Those failings on the part of the Trust have been highlighted and there are now expectations it will have to meet.”