NHS trust's neglect led to Essex mum's death, inquest told

Angela Ling
-Credit: (Image: Ling Family)


A ”fiercely protective” 49-year-old mother from Chelmsford would still be alive if it were not for a set of “clear and serious” clinical deficiencies Essex's NHS mental health trust has been told. A seven-day inquest held at Chelmsford Coroner's Court concluded that Angela Ling died as a result of suicide contributed to by neglect on the part of Essex Partnership NHS Trust.

The inquest, which concluded on June 28, 2024, heard how Angela would have likely survived had she received the care and treatment she needed for a diagnosed recurrent Major Depressive Disorder. Dr Dinesh Maganty told the inquest that several failings in Angela’s care, which included a failure to consult with Angela’s family throughout her care, a failure to provide consistent pharmacological treatment and a failure to provide any psychological treatment contributed to her death on December 1, 2021.

As part of the character sketch read out in court, Angela’s mother said: “Angela was never a person to do things by halves, in her own words, 'You know me I’m all or nothing'."

"She was a loving Mum and fiercely protective of her children, her family, her home and her children were everything to her," Angela's mum said.

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"She had in the past talked of looking ahead to her retirement years. She told me she just wanted to potter in her home, tend her garden, grow herbs and vegetables. She had talked of wanting to extend the family home, so that her children could bring their children home for family events. She had recently said she wanted to travel and to have family holidays. However, tragically, this future was not to be. Above all, she was our beautiful, precious, irreplaceable daughter and we loved her beyond measure.”

After around a month of concern, on November 17, 2021, following an overdose, Angela was taken to Broomfield Hospital. The court heard that Angela’s care coordinator made it known to EPUT’s gatekeeping team that Angela needed inpatient care, that she was hoarding her medication, and her family and the CMHT could not keep her safe.

But despite the care coordinator saying she required inpatient care Angela was discharged home on November 19. She had two at-home meetings with EPUT’s Home Treatment Team on Saturday, November 20 and Sunday, November 21. The expert at the inquest said Angela should have been referred for an MHA Assessment on November 19 2021 and on November 21 2021.

On Sunday, November 21, the professionals in attendance noted that Angela was distressed, catastrophising and unable to rationalise and process information. At this meeting, Angela reported she was going to end her life by overdose but had no medication in the house.

Her care was not escalated at this stage and her family were not offered any additional support. Later that day, Angela attempted to take her own life. She was taken to hospital and after receiving a period of intensive care it was determined that Angela had suffered irreversible brain damage.

In a joint statement, Angela’s children said: “Our mum was just 49 when she died. She was above all our mum, the most important job in the world to her, and we loved her more than we could put into words. Our hearts have been broken because she deserved better and so much longer, and it was a death that should have been avoidable.

“She was kind, generous, clever, bubbly and fun. She was feisty, tenacious and held strong opinions and was well educated entirely by her own determination. She loved spending time with her family and dogs.

“We were doing all we could to get mum the support she needed and we are glad the coroner recognised this in his conclusions. Sadly Mum did not get the help she needed but we hope things will change to mean that others are not put in the same position that we were.”

Leigh Day partner Anna Moore said: “The mental health services at Essex are already under scrutiny by way of an Independent Inquiry as clearly things are going wrong at the Trust. There were clear and serious deficiencies in the care offered to Angela and her family and I hope, instead of adopting a defensive approach, EPUT take steps to carefully consider the conclusions of the Coroner and take steps to make things safer for patients in the future.”

The trust says it is "continuously working" with staff, patients, their families and carers to enhance the quality of care. It adds people with lived experience have been employed in designated roles across the trust, ensuring that "patient voice is the heart of the organisation".

Paul Scott, Chief Executive of Essex Partnership University NHS Foundation Trust (EPUT), said: “I am sorry for the mistakes that were made in caring for Angela and offer my deepest condolences to her family and friends following their tragic loss.

“We recognise the vital role families play in the care of their loved ones, and we are focussed on working closely with them, our patients, partners and lived experience ambassadors to drive improvement across our services and provide the best individual care at all times.”