Mental health: Lowri Miller's mother says hospital failed her

Sue Miller says her daughter Lowri was "failed miserably" by the mental health service

A bereaved mother said her daughter was "failed miserably" by a mental health service now under review by inspectors.

Sue Miller feels Lowri, 32, should not have been discharged from the Royal Glamorgan Hospital in Rhondda Cynon Taf. She died the next day.

Healthcare Inspectorate Wales (HIW) is reviewing the mental health service in Cwm Taf Morgannwg Health Board over concerns about discharges.

The health board said it would "take on board" any HIW recommendations.

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Lowri died from a "sudden cardiac event" at a friend's house after taking a mixture of drugs.

An inquest found doctors were unaware she had a plan to end her life when she was discharged.

Coroner Graeme Hughes recorded a narrative verdict, saying he could not be convinced Lowri had intended to end her life and that "there was no contribution to her death arising from the clinical decision to discharge her."

Lowri's family said they were disappointed with that conclusion and believe there were failings in her care.

The inquest heard Lowri had told her social worker she "did not want to be alive anymore" and had a plan to end her life.

But those concerns were not relayed to the unit's clinical director before the discharge decision was made, despite the social worker telling a member of the nursing team.

'They didn't listen'

Lowri was discharged days after taking an overdose while in the mental health unit

Lowri had been to the Royal Glamorgan at Llantrisant because of self-harming on several occasions prior to her death.

She was admitted to the hospital on 4 February 2020 after taking an overdose and was identified as a "high risk of suicide," according to a review conducted by the health board.

She took a further overdose while in the hospital's mental health unit and self-harmed. She was discharged after three days.

Her mother Sue, from Beddau, Rhondda Cynon Taf, believes Lowri was seen as a "nuisance."

"With the discharge it was totally against our wishes," she said. "We couldn't have been more strong in how we felt that she was a grave risk to herself.

"I didn't want her just to be a statistic that they would learn from. And here we are, because they didn't listen."

Lowri's sister Rhiannon said the hospital did not help her sister in her "dire need".

From 'happy girl' to troubled teen

Lowri had a happy childhood, say her family

Lowri's sister Rhiannon questions the conclusion her sister's death was "not predictable or preventable"

Sue and Rhiannon remember Lowri being a "very happy little girl" who had a "fab childhood" and loved football, but she "went down a bad path" in her teenage years.

She got in trouble with the police on several occasions and ended up being jailed. She was later diagnosed with an emotionally unstable personality disorder.

After prison, her mother says she had several "happy and healthy years," but her mental health deteriorated in 2018 following a bereavement.

BBC Wales Live has seen a review carried out by the health board following Lowri's death which concludes that "this tragic incident" was "neither predictable, nor preventable," but it also raises questions about her care at the hospital.

After prison, Lowri enjoyed several happy years, but her mental health was later affected by a bereavement

The review found there was a "lack of exploration" of the concerns raised by Lowri's social worker and mother about her state of mind and "suicidal thoughts" and that there were "clear expressions of hopelessness and distress" from her.

It states there was no mechanism to pause the discharge, despite the fact that Lowri was found on the bathroom floor after self-harming with a razor blade the day before and had told staff "no one was listening to her".

It recommended that a process should be established whereby any member of the team looking after a patient, or a family member, can temporarily pause an inpatient discharge if they feel it to be unsafe.

It also finds that there was no evidence of the "escalation process" for "frequent attenders" being activated.

'She didn't trigger escalation policy'

Lowri's sister Rhiannon questions the conclusion her sister's death was "not predictable or preventable".

"In that report, they highlighted themselves that she didn't trigger their own escalation policy. So they failed her, massively so.

"If they did nothing wrong with my sister, why is there a new discharge plan that was implemented, because of how they discharged Lowri?"

Sue would like to meet the health minister to discuss "what is going on" with the mental health service at the hospital.

"They haven't treated my daughter as a human being. They have failed her miserably and we've lost someone so special in our lives."

What happens next?

Sue and Rhiannon are looking for answers

There are also broader concerns about the area's mental health service.

Shortly after Lowri was released, Zara Radcliffe, who went on to kill a man in a supermarket, was discharged from the hospital after being assessed as "low risk."

Later that year the health board said it would conduct a "rigorous" review of the case.

HIW's review is assessing whether Cwm Taf Morgannwg's arrangements for the discharge of mental health patients into the community are "safe and effective".

'Sincere and heartfelt condolences'

It was prompted by serious incident notifications submitted to the Welsh government, external concerns received by HIW and previous HIW mental health inspections.

A report is due to be published in August.

Greg Dix, Cwm Taf Morgannwg health board's executive director of nursing and patient care, said: "We would like to offer our most sincere and heartfelt condolences to Lowri's family once again.

"We appreciate how hard it is to lose a loved one, especially in such tragic circumstances.

"We accept the coroner's verdict following the inquest into Lowri's death.

"As a health board we are committed to listening and learning which then allows us to improve the care and service we deliver to our patients.

"As part of that listening and learning, we will now work with HIW on their report and look forward to taking on board any recommendations they may make.

"Our thoughts and sympathies continue to be with Lowri's family as they try to come to terms with their loss."

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