Coroner highlights 'lapses in care' of York woman who took her life after months without contact

A coroner has ruled there were lapses in the care of a vulnerable woman who took her own life after going three months without contact during the coronavirus lockdown. 

Frances Wellburn, from York, had been under the care of Tees Esk and Wear Valley NHS trust, a group which has been criticised for previous failings of other patients

They say improvements have been made, but Frances' family believe with the right care she would still be here.

Frances Wellburn retired to York from London to be closer to her family.

The 56-year-old had dedicated her career to the NHS but her loved ones say when she really needed it, she was abandoned.

Her sister Rebecca Wellburn told ITV Tyne Tees: "For 55 years Frances lived a full and active life but in her final ten months, she suffered from a serious episode of psychotic depression.

"There is every reason to believe that with the right care she would have recovered from this."


Timeline of events

  • In September 2019, Frances Wellburn was first brought under the care of Tees Esk Wear Valley Trust when she was admitted to Cross Lane Hospital in Scarborough.

  • Following treatment, she went under the care of a community mental health team who carried out weekly checks.

  • When lockdown hit in March 2020, Frances had no contact for three months. The inquest heard the Trust failed to follow guidelines.

  • In May 2020, contact resumed although Frances' mental health was deteriorating and she attempted suicide. She was readmitted to hospital.

  • In August 2020, while back under the care of the community team she took her own life at her home in York.


Today (23 March) at the inquest into her death, the coroner returned a narrative verdict and told Frances' family there had been lapses in her care, but it was not possible to say if they contributed to her death.

However, her loved ones disagree.

Her sister Rebecca said: "We don’t believe her relapse in May was inevitable.

"It seems clear it was linked to her stopping medication during the three month period she had no contact.

"I hope Tees Esk and Wear Valley recognise more could have been done to support Frances and prevent her tragic suicide."

Frances Wellburn with her sister Rebecca

Following Frances' death, the trust carried out its own investigation.

It found there had been a clear gap in her care during lockdown, that there had been a lack of clarity around her medication and it found better efforts should have been made to involve her family.

In a statement Elizabeth Moody, director of nursing and governance at the trust, said: “Our hearts go out to Frances’s family and friends during this incredibly difficult time. We remain deeply sorry for their loss.

“Providing the best possible care for the people we support is the most important thing we do, and we have worked hard to make improvements following our own review into Frances’s tragic death in 2020.

“We shared our findings with Frances’s family and we are planning to work together to support further learning and improvement in our community mental health care.”