A woman with suicidal thoughts called funeral homes multiple times
5 mins read

A woman with suicidal thoughts called funeral homes multiple times

An NHS mental health service has apologised after a woman in its care committed suicide after she repeatedly called a funeral home to tell them she was planning to kill herself.

Katie Stonebridge, 27, told staff at the East London Foundation Trust (ELFT) she would not live to see her next birthday before she was found dead in her Bedfordshire flat in November.

The coroner highlighted gaps in services for autistic people.

ELFT has announced the introduction of new safeguards to protect patients.

Katie’s mother, Julie Stonebridge, said her daughter felt “overwhelmed” by the number of staff and services she came into contact with in the months before her death.

Katie, who was also diagnosed with emotionally unstable personality disorder, was found in her Sandy home.

An internal ELFT patient safety report found that the patient’s caregivers “did not adequately consider her autism diagnosis in care planning and communication.”

“There was a lack of a systematic, collective and comprehensive assessment by the services in view of the patient’s deteriorating mental condition,” it added.

The London-based trust has signed a contract to provide mental health services in Bedfordshire.

A woman with suicidal thoughts called funeral homes multiple timesA woman with suicidal thoughts called funeral homes multiple times

Katie’s family outside Ampthill Coroner’s Court, including her mother Julie (second from right) (Matt Precey/BBC)

Two funeral directors said Katie had contacted them in the month before her death, and one admitted that she had called them repeatedly to plan a funeral because she was considering taking her own life.

During one such visit to her home, she was visited by the Mental Health Crisis Team, but the report said an email they sent asking for continued treatment “was not acted on”.

It noted “a lack of professional curiosity about the patient, for example evidence that she may have active suicidal plans that were not explored.”

Back of a woman in a hoodBack of a woman in a hood

Julie Stonebridge said she was sceptical about the changes promised by ELFT (Matt Precey/BBC)

Katie told ELFT staff she had a drinking problem, which left her usually clean apartment littered with broken glass and blood.

Her behaviour was often described as “typical”, but the report highlighted concerns that this meant staff had “normalised” her behaviour.

She had a history of self-harm, and ER visits became more frequent as her condition worsened in the last weeks of her life.

Two months before her death, Katie was transferred from the Care Programme Approach (CPA) intensive care facility where she had been since she came of age.

Her commitment to CPA was ignored, the report said, and the breakup was a source of stress for her.

It was added that subsequent contacts took place mainly by telephone and with the staff on duty.

“We haven’t learned anything”

Emma Whitting, the coroner at Mrs Stonebridge’s inquest, highlighted research suggesting that people with autism are seven times more likely to die by suicide than neurotypical people, in a letter to the ELFT seen by the BBC.

Three years ago, the same coroner issued a Report on the Prevention of Future Deaths in relation to Luke Wilden, another autistic patient.

His mental health deteriorated when, after turning 18, he was moved from assisted living to independent living in Bedford.

Julie Stonebridge said the case was reminiscent of what happened to her daughter and she was concerned that “no lessons have been learned from this report”.



In the letter, Ms Whitting mentioned Luke’s death and noted that “recent policy changes regarding the care of people living with autism” “do not appear to have been implemented in practice”.

Like Luke, Katie also moved into her own apartment a few months before her death.

Her mother felt there were too many professionals involved in the case and no single point of contact, leaving her daughter confused and unresponsive to key information.

“Police safety emails have been sent to the Community Mental Health Team,” she said.

“They sent emails to the hospital and because there was no one to receive them, they went in the wrong direction.”

An ELFT spokesman said: “Our thoughts and deepest condolences go to Katie Stonebridge’s family and friends at this difficult time.

“We apologise unreservedly that the standard of care provided was not as high as it should have been and we are reviewing our provisions in light of Katie’s death.”

They added that they were “determined” to resolve the issues raised by the coroner.

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