A mum was tragically found dead seven days after her last contact with Roseberry Park mental health hospital.
Laura Marie O’Malley was an informal patient at Roseberry Park Hospital, a psychiatric hospital run by the Tees, Esk and Wear Valleys (TEWV) NHS Foundation Trust. The 24-year-old was last seen on the ward of the facility on Marton Road on November 9, 2022.
The mum-of-three was granted overnight leave to stay at her cousin’s house and last spoke to a staff member on November 10 – her last known contact. Ms O’Malley’s family claim she was “massively failed” as they were contacted four days later – on November 14 – asking if they knew her whereabouts or any phone numbers of people she may have been with.
The “bubbly” and much-loved Middlesbrough woman was tragically found dead on November 18, 2022, at her home address on Newbury Avenue in Whinney Banks by Cleveland Police officers. At an inquest, held at Teesside Coroner’s Court on Wednesday, Ms O’Malley’s mum Anne told the hearing that she felt “nobody cared enough” and “there was no urgency there to look for her”.
Evidence provided by two trust employees, Jane O’Neil and James Donegan, found that learnings were identified through Ms O’Malley’s death – and subsequent investigation – around the missing patient procedure. A post mortem report conducted by Dr Sowmya Venkatesan ruled Ms O’Malley’s cause of death as ‘1a pressure on the neck due to 1b hanging’. A toxicology report also found alcohol and cocaine in Ms O’Malley’s system at the time of her death.
A statement from Ms O’Malley’s adoptive mum was read aloud at the inquest which was held in Teesside Magistrates’ Court. She described her daughter, who was diagnosed with emotional unstable personality disorder and “complex trauma”, as a “much-loved daughter” who “suffered from mental health issues all her life”.
The inquest heard that she had “severe attachment issues” after having numerous foster homes before 18-months-old. However, at the age of four, Laura, along with her older brother, were sent to Blackpool to be with their younger sister.
However, the foster carers “couldn’t handle their behaviour” and were returned to Anne and her partner. During her statement, the mum told how she adopted the three siblings but “Laura was a different child”, citing her “temper tantrums”.
“I always had a close relationship with her,” she said. Adding that she believed she loved her more than anyone else in the world, apart from her younger sister Lily.
She stated that before her death, her daughter “seemed happy”. The mum told how she had phoned her telling her that she was OK and that she would be in touch.
‘They massively failed her’
When asked by assistant coroner Andrew James Blair about Ms O’Malley’s personality, her mum responded that she was a “feisty and bubbly” child. However, she added that she was “very troubled” and “pushed people away”.
PC Armstrong provided a statement to the coroner and confirmed that she was on mobile patrol when dispatched to a report of a missing person. She attended Ms O’Malley’s home but received no reply.
However, she entered the property and found Ms O’Malley. There was evidence of drug use but found “no sign of disturbance or third party involvement”. Paramedics were called to the scene and Ms O’Malley was sadly declared deceased at 12.50am.
Dr Sagarika Nag, a medical practitioner at TEWV, documented Laura’s desire to change accomodation with Thirteen housing, her declining mental health and ongoing suicidal thoughts following an inpatient stay at James Cook University Hospital from October 20 to 27. Ms O’Malley was discharged on October 27 but later contacted the crisis team in a “distressed” state as she “didn’t feel safe”.
She was advised to attend Roseberry Park for an assessment. Chantelle Hunter, crisis clinician at TEWV, documented Ms O’Malley’s “tearful and extremely distressed” state during the assessment, where it was decided she would be an informal patient due to the “significant risk to herself”.
Dr Evemenko-Lowrie, who was involved in Ms O’Malley’s care on Elm Ward in West Park Hospital in Darlington, described how she presented with ‘low mood, suicidal thoughts and hearing voices of someone shouting’. Ms O’Malley was admitted to the hospital on October 29 before being transferred to Roseberry Park on October 31.
Timeline of events
20/10/2022 – A&E visit leading to admission
28/10/2022 – Discharge from James Cook University Hospital
29/10/2022 – Psychiatry assessment and admission to West Park
31/10/2022 – Transfer to Roseberry Park and then unplanned overnight leave
01/11/2022 – Return to Roseberry Park and formulation meeting
03/11/2022 – Overnight leave at friend’s house and didn’t collect medication
05/11/2022 – Overnight leave requested at 11pm – not granted
08/11/2022 – Requested overnight leave but didn’t go
09/11/2022 – Left ward at 2.20pm – last time at Roseberry Park
10/11/2022 – Spoke to ward staff on phone and discharge planning meeting held in Ms O’Malley’s absence
11/11/2022 – Did not attend Thirteen housing meeting
10-14/11/2022 – Voicemail messages left on Ms O’Malley’s phone
14/11/2022 – Contacted Ms O’Malley’s mum and Cleveland Police to conduct welfare check which was declined
17/11/2022 – Ms O’Malley logged as a missing person with Cleveland Police
18/11/2022 – Found deceased at home address
Last contact with hospital
The inquest heard how Ms O’Malley was last seen at Roseberry Park on November 9, 2022 when she left the ward at 2.20pm. She stated that she would return at 5pm, but after calling around the same time she asked for overnight leave to stay at her cousin’s house in Hemlington.
On November 10, she was contacted by staff on the ward and Ms O’Malley stated that she would be back by 2pm. This was her last contact with Roseberry Park.
Cleveland Police were contacted on November 14 to request a welfare check after Ms O’Malley’s mum confirmed that she did not have a cousin in Hemlington – where she claimed she had gone. The force declined to carry out the check due to “no indication of threat to life”. Three days later on November 17, she was reported to Cleveland Police as a missing person and 12 hours later sadly found deceased.
In a review contacted by the trust, it found eight key learnings and missed opportunities from Ms O’Malley’s death and review of her care. The areas involved reasonings for transfers between hospitals; domestic abuse concerns; intervention plans and family views; a list of contact numbers are kept for patients; safety plans reflect the patient and are up to date including not “cutting and pasting previous entries”; police and bail information; review the missing person’s policy.
‘Nobody cared enough’
Ms O’Malley’s mum told Associate Director Of Nursing at the trust, Jane O’Neil: “Right care, right person clearly doesn’t work. If someone told us Laura was missing we could have found her. Nobody cared enough.”
She continued: “How many days does that take? Phone calls and voicemails to Laura that’s not good enough. You failed her. The future changes, it’s too late for us.”
The trust manager responded that she agreed that staff should have contacted the family and visited Ms O’Malley’s property to conduct a check on her. “That should have happened,” she said. “We reported that in our learning.”
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