Woman who lost brother and mum in mental health battle devastated as coroner rules NHS failures did not cause tragic deaths

Marshall Metcalfe, Holly Ireland’s 17-year-old brother, died on May 7, 2020 after falling from the roof of a Sainburys department store in Talbot Road, Blackpool.

Just a month later, on June 7, Ms Ireland, 44, died at her home on Healy Road, St Annes, from the combined effects of a high dose of methadone, fatty liver disease and bronchopneumonia.

Both mother and son had schizophrenia and were under the care of Lancashire and the South Cumbria NHS Foundation Trust Mental Health Services in Blackpool.

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Marshall Metcalfe with his mother Jane Ireland and sisters Missy and Holly

An independent investigation found that “opportunities were lost” in Marshall’s care, while Lancashire social services admitted there had been a serious break in communication between departments.

However, after a two-week investigation, coroner Alan Wilson determined that it could not be established that these failures directly caused Marshall and Jane’s death when they died.

“People didn’t do the things they should have done, or they didn’t know the things they ought to do.

“I still can’t wrap my head around it. Ending it like this is very frustrating, and I feel like it’s just another example of a system failing for people with mental illness.

“I am angry, upset and frustrated, because to me it is very clear that the people who should have helped my mother and brother have missed all the warning signs. They should have been protected, and they weren’t.”

Her family described Jane, a mother of three, as “a fun and loving person who lit up every room she entered”.

“She was a talented makeup artist and worked in theater productions and photo shoots. She was also a qualified Reiki therapist and she dreamed of opening her own retreat.”

However, she has struggled with mental health issues since 2010, when she was viciously attacked by her abusive ex-boyfriend.

She moved with her children from Burnley to St. Annes in search of a new life. But her mental health continued to deteriorate and she was eventually taken to hospital after taking two drug overdose.

A year before her death, she would hear 13 different voices in her head, including that of the god Yaruh, drinking excessively and neglecting her antipsychotic medication.

Meanwhile, Marshall’s mental health declined significantly in 2018 and he had two extended stays at The Cove unit in Hesham for children with complex mental health needs, final residency lasting from February 2019 to January 2020.

During Marshall’s lowest point at The Cove in the summer of 2019, his ability to communicate deteriorated and he was making annoying noises and rolling on the floor.

Holly said: “My mum called the doctor in December (2019) and said she was hearing voices and really struggling, and then they released Marshall into her care in January. It was the worst thing they could do because neither of them was stable. She wasn’t safe at all.”

She added, “The system is down and has failed me again after so many cases over the past decade. These have been the hardest times of my life and I don’t feel like anyone else has to go through what I and my family have gone through, but unfortunately this has become the case for many – not just in This country but around the world.

I think it shows that the system is intrinsically corrupt and is not there to genuinely care for people.

“However, I do accept some positivity regarding how much light the investigation has shed on the failures in the current system. I will continue to fight it for my loved ones and for all other people who have gone through or are grieving at the hands of the mental health system.”

“I still have a lot to work through, but this is not the end of my struggle to change this broken system that we are all currently subjected to. I will push to advance the cause and hope in the future to connect with other families who are fighting this fight and who are fighting the same.”

“Time and time again we see families’ concerns being ignored, and mental health and social services failing to communicate and provide comprehensive support. These are the basics of care for anyone with mental health or support needs,” said Lucy McKay, a spokeswoman for INQUEST, a charity representing bereaved families.

“Seeing a family losing both their son and their mother to this kind of basic and well-documented issue is as tragic as it is deeply frustrating. We must see national action and investment in mental health and local services to enable mutual support. While professionals need to make a cultural shift towards listening to Family advocates are like Holly, so people no longer have to fight for their families’ lives.”

More deaths must be prevented

Marshall was a pupil at Lytham High School known for social services. However, when he was divided into the children’s mental health unit at The Cove, social services did not continue, and there was no arrangement when he left.

After the investigation, which came to the conclusion of a suicide in the Marshall case, coroner Alan Wilson announced his plans to write to Secretary Jillian Keegan at the Department of Health and Welfare, in order to prevent further deaths.

The court heard that when Marshall left The Cove on January 6, 2020, the team at the unit believed his mother was the best person he took care of — but they thought social services should have been involved in his layoff.

The lack of communication between the social service and mental health teams has resulted in Ireland’s deteriorating mental health being underreported.

Holly raised concerns that her mother was not good enough to take care of Marshall due to her mental health issues. However, no alternative accommodation was sought for Marshall, as he came from a loving home.

In a statement, his family said: “(Marshall) loved football and supported Burnley. He also enjoyed hunting and playing. He was a fierce and loyal friend. We are saddened that we will not see him grow up and fulfill his dreams.”

Holly added: “While I am happy with the preparation of this report, I still cannot say that I am at all happy with the outcome of the investigation.

“No report has been carried out to prevent future deaths in relation to the parking lot where Marshall died. We heard from the council representative that they had informed Sainsbury of the 2017 dangers. However, it took until 2020 and Marshall’s death for permanent barriers to be put in place. The council representative of the inquiry said it was They have no power to compel private companies to take any steps to make known suicide hotspots safer. This lack of regulation is putting future lives at risk across the country.”

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