The family of a young mum who was found hanged on a mental health ward have spoken of their heartbreak after an inquest into her death revealed a catalogue of failings in her care.
Rachel Morgan, 28, had always been a strong, capable mum who had coped well with the challenges of becoming a mum aged 17, and raising a child with complex needs.
But when Rachel, from Bolton, gave birth to her second baby around 10 years later, she started to suffer with severe postnatal depression and psychotic episodes.
She was found hanged on a mental health ward at Trafford General Hospital in April after being sectioned days earlier.
An inquest revealed a series of failings and missed opportunities in Rachel’s health care in the months leading up to her death.
Rachel’s devastated mum, Jill Robinson, said her ‘beautiful daughter’ had been let down by the services that should have kept her safe.
During six days of evidence at Stockport Coroner’s Court, a jury heard how Rachel fell ill shortly after her second baby was born in September 2015.
A month later Rachel told her mum she was having disturbing visions of her newborn baby being thrown out of a window and run over.
Jill took Rachel to see her family GP where she asked if she could be suffering with postpartum psychosis - a severe episode of mental illness which occurs suddenly in the days or weeks after having a baby.
But after being warned off ‘going down that route’ by her doctor, she was diagnosed with depression, prescribed Diazepam and sent home.
Jill said the doctor’s comments left Rachel terrified of being labelled as ‘mad’ or of going into hospital and never coming out again.
She said: “Rachel was a brilliant mum. She was resilient and she coped well.
“She’d been really looking forward to having another baby. She’d wanted another one for about two years.
“She’d bought lots of baby clothes and a new pram. Everything had to be the best.
“It was when she gave birth that she started suffering with a low mood. She coped initially.
“But then started having low moods and having these visions..”
As Rachel’s mental health problems deteriorated, she became more detached from her baby.
Her family and friends stayed with Rachel to watch her 24 hours a day, but on October 15, Rachel locked herself in her bedroom and cut both her wrists.
It was the first of several suicide attempts in the months leading up to her death. Her partner, Ashley Podmore, said Rachel spent hours talking to people on suicide forums and researching methods of taking her own life. She ordered hundreds of pounds worth of drugs from China over the internet, and told her mum she wanted to see priest to be exorcised. In January 2016, Rachel was found by police ‘ready to jump’ from Barton Bridge.
Jill said what Rachel really wanted was to be referred to a special mother and baby unit at Wythenshawe Hospital.
Medics at the Medlock ward at Trafford General made the referral to Wythenshawe in January, yet the move was ‘put on hold’ by social workers
Jill said: “Rachel thought that would be the best place for her and her baby.
“It was like they were dangling in front of her. But it never happened.”
Rachel’s mental state became worse in April when she was sectioned and admitted to the Medlock Ward at Trafford General.
“To be honest when she was sectioned I felt relief,” added Jill.
“Even though I didn’t like the thought of her locked away, I did feel she was in the right place. I felt she was safe.”
Rachel was placed on an amber suicide risk by ward staff who soon upgraded it to red - the highest risk rating.
Rachel told relatives and staff she had constant thoughts of ending her own life - but she only place on intermittent ‘level 3’ observations.
Despite numerous phone calls to the ward from Jill, who was concerned her daughter was at imminent risk of taking her life, the observations were never increased.
Rachel was found hanged and unresponsive in her hospital room on Saturday, April 16 and died in Salford Royal on April 24, 2016.
A jury at Stockport Coroner’s Court identified a number of failings in Rachel’s care.
They highlighted contradictory accounts of handovers between staff regarding Rachel’s symptoms and risk of suicide.
A number of observations about Rachel were not documented by staff or updated on her risk assessment.
The jury stated: “On the 15th of April the family highlighted specific concerns regarding Rachel’s safety which were discussed by nursing staff, updated on the Paris records but were not added to the risk assessment. The levels of observation were not raised.”
The jury concluded Rachel had died as a result of suicide.
Rachel’s relatives said they were satisfied with the inquest’s findings but said they will never get over the heartbreak of losing her.
Jill said if her daughter had been given the right treatment, she could have overcome her illness and made a recovery.
She added: “There no words to describe the pain I feel over losing Rachel - life will never be the same again without my beautiful girl.”
The family’s lawyer, Zak Golombeck, a clinical negligence specialist from Slater and Gordon, said: “This inquest has highlighted several failings and missed opportunities to help a devoted young mum who only wanted to be well and able to look after her children.
“For those like Rachel who are battling mental illness, it shouldn’t also be a fight to get access to the services they so desperately need.”
Gill Green, director of nursing and operations for Greater Manchester Mental Health NHS Foundation Trust said: “The quality of care we offer to our service users is our main priority and therefore we will look carefully at the circumstances surrounding this incident.
“We will ensure learning from the outcomes of the report, and any recommendations in regard to improvements in our care, are implemented.
“However, our staff remain devastated at this outcome and express their deepest sympathies to Rachel’s’ family and friends.”