Middlesbrough mum-of-four found dead by brother day after mental health assessment, inquest hears

The family of a much-loved Middlesbrough mum have raised concerns about the mental health care she received in the days before her death, an inquest has heard.

In August 2023, Rachel Grimes was tragically found dead in her home the day after she was assessed at Roseberry Park Hospital. Now an inquest into her death has heard how Rachel's family have raised concerns about actions of staff from the mental health hospital - which is run be the Tees, Esk and Wear Valley NHS Foundation Trust - and Changing Futures, a joint initiative by Middlesbrough and Redcar and Cleveland councils.

In a statement - which was read out by Ben McCormack, the family's legal representative - Lynne Burke, Rachel's aunt, said: "As a family, we have suffered a massive loss and none more so than Rachel's children. We want to make sure that lessons are learned from what happened to Rachel so that families do not have to go through what we have gone through in the future.

"We are deeply concerned by the failure of staff at Roseberry Park to safeguard Rachel and detain her when she was assessed on August 4, 2023. We believe that it would clearly have been the right step to take.

"We are also concerned about the involvement of Changing Futures in Rachel's care and the level of reliance Rachel had upon Caitlin [her key worker], who then simply failed to adequately pass on concerns for Rachel when she was clearly in crisis."

Final text to key worker

The mum-of-four's mental health had been deteriorating in the week before her death, HM assistant coroner Paul Appleton heard. On August 3, 2023, Rachel contacted her Changing Futures key worker Caitlin Harrison, who arranged a meeting with her the following day.

Following a "back and forth" between services, Ms Harrison drove the 31-year-old, who had expressed thoughts of suicide, to the mental health hospital, in Marton Road, where she was assessed. During the assessment, Rachel's mood is said to have improved and she was discharged with medication to receive support in the community.

Ms Harrison then took Rachel to see her dad before she was dropped off in the vicinity of her brother's home by Ms Harrison. The inquest heard that Rachel had an altercation with her brother and had disclosed to Ms Harrison that she had made violent threats - which the key worker emailed one of the assessing nurses Andrew Reid about to update him on Rachel's emotional state.

The messages between Rachel and Ms Harrison were read out during Thursday's proceedings. Rachel texted Ms Harrison saying at 4.22pm on August 4: "I ended up having a fight with him. He's at my house now, think he's going to put my windows in."

Ms Harrison then replied six minutes later, from her work phone, to say: "Oh Rachel the only thing I can advise is ringing the police. My work phone is about to go off for the weekend but please keep safe."

Rachel responds at 4.33pm saying: "I'm f****** done with everything Caitlin honestly can't take no more."

Giving evidence at the hearing, Ms Harrison confirmed she had switched her phone off and didn't receive the message until 10.05am on Monday morning. Mr Appleton said: "We heard earlier that one of the concerns from Rachel's family is that Rachel had become over reliant on you as her key worker at the time. Do you have any view on that?"

Ms Harrison said she and other key workers develop professional relationships with the people they support and there was nothing "unusual" or out of the ordinary with the service provided to Rachel. The key worker, who is now an enhanced case worker in the organisation, said Changing Futures is not for emergencies and is used to help people access specific services.

The inquest heard that while Ms Harrison's voicemail states her working hours, there is no automatic message to anyone sending her a text - even though this is an approved and encouraged method of communication with service users.

Suicidal to 'calm and jovial'

Rachel was previously diagnosed with emotionally unstable personality disorder. "Rachel would often reflect the mood of others in the room and her mood could change instantly," Lynne's statement read. "I would expect that the community psychiatric nurse assessing Rachel's needs would have been aware of this and not just rely on her presentation and how she said she was feeling at that particular moment."

The inquest heard how Rachel had expressed thoughts of suicide to Ms Harrison and appeared agitated. She had informed family members that she was going to hospital and may be admitted or detained and had arranged for care for her dog if this was the case.

But as her assessment progressed, Rachel's mood is said to have improved, according to Mr Reid, who worked for Parkside, and Robyn Hall, a nurse with the crisis team at Roseberry Park. "She was able to engage in the review... she was in good humour and was jovial by the end of the assessment," Mr Reid said.

Rachel had also previously discharged herself from impatient services in the years previous as she didn't like the environment.

The coroner's court heard that an internal investigation had found there was a lack of professional curiosity. But nurse Reid said a lot of the conversation had revolved around social stresses which is why a longer review would be carried out.

Issues were also raised about record keeping, something Ms Hall accepted in evidence. She had entered her notes retrospectively following Rachel's passing.

'Passed from pillar to post'

The coroner's court heard how Lynne had played a big role in ensuring Rachel attended appointments and helped with mental health support. Rachel's mental had been deteriorating in the week before her death. In her devastated family's statement, which was read out in court, Lynne speaks of how two trusted friends had stayed with Rachel, abused her trust and stolen from her.

Rachel had also rowed with two family members and was having hallucinations - something she hadn't experienced prior to this - and had two fits or seizures, one while she was in Morrisons. Reading Lynne's statement, Ben McCormack, representing the family, said: "Rachel was in a really low place and had again made threats that she would end her life [by August 3, 2023]."

It was Ms Harrison who called the crisis team on Rachel's behalf but was told she must speak to Parkside Mental Health Resource Centre, where Rachel had been referred. But Ms Harrison was instead told she needed to speak to the crisis team.

Speaking at the hearing, Ms Harrison said it was a "back and forth" with Mr McCormack adding it was not a simple process and questioned whether Rachel would have been able to get in the front door to access help with the key worker's support.

"I don't know if she would have [been able to] without my help," said Ms Harrison, although she confirmed she couldn't be sure either way.

Rachel had battled with mental health issues for around six years following the death of her mum. She was tragically found by her brother on August 5 and, despite CPR by a police officer, she was declared dead at her home. A toxicology report found high levels of zopiclone - which she had been prescribed - as well as low levels of other drugs within the therapeutic range.

Following a post mortem, Dr Sowmya Venkatesan found Rachel died as a result of hanging. The inquest continues on Friday, March 21.

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