Berkshire NHS trust's mental health services changes after death

Zoe Lyalle died in May 2020

An NHS trust said improvements had been made to the way teenagers using mental health services transition to those for adults after an 18-year-old woman with autism took her own life.

Zoe Lyalle's family, from Reading, said it felt "utterly let down" by the Berkshire Healthcare NHS Foundation Trust and her specialist school.

But coroner Ian Wade QC concluded neither had any major impact on her death in May 2020.

He recorded a verdict of suicide.

Ms Lyalle had been diagnosed with autism spectrum disorder and suffered with depression, anxiety and disordered eating, the inquest on Thursday heard.

She was in the care of the trust's adolescent mental health team from the age of 14.

Her family said she suffered a five-month delay in accessing adult services, until March 2020, which contributed to a "deterioration" in her mental health.

Though the coroner said the delay was "preventable", he found it had "not played more than a minimal part" in her mental health declining.

Mr Wade concluded the inquest into Ms Lyalle's death at Reading Coroner's Court on Thursday

Catch22 withdrew Ms Lyalle from GCSE exams, to be taken in summer 2020, due to poor attendance, which her family said had left her "losing all hope for the future and removing her sense of purpose".

But the coroner said it had not "caused or contributed" to her death.

He said he also found both the school and trust staff had acted with "compassion" towards Ms Lyalle.

In a statement, a Berkshire Healthcare NHS Foundation Trust spokesperson said: "As a trust we recognised that Zoe's transition into adult services was a difficult time for her.

"Our investigation, following Zoe's death, found that this process needed to be improved to better support other young people in the future."

It added it had implemented a "new procedure" for staff to follow, and had "provided additional resources and training to help our clinicians feel more confident when working with patients with autism".

Catch22 sent its "deepest sympathy" to Ms Lyalle's family.

A spokesperson added: "The ethos of Catch22 is to work with our young people to give them the best possible chance to achieve their educational goals," they added.

"Sadly as an educational facility we cannot provide specialist mental health services as reflected at the inquest."

Correction 25 May 2022: An earlier version of this story incorrectly named the trust as the Royal Berkshire NHS Foundation Trust rather than the Berkshire Healthcare NHS Foundation Trust.