A beloved mum was let down by mental health services before her death, an inquest has ruled.

June Challis from Deal was just 55 when she died after choking on a teabag while on a psychiatric ward.

The mum of two, known as Angie from her middle name of Angela, had previously been admitted to hospital while experiencing severe post-natal depression.

The inquest heard that she began to experience mental health issues once more following menopause in 2017, deteriorating from 2020.

She was given a diagnosis of ‘Treatment Resistant Depression’, and was treated by Community Mental Health Teams with the involvement of the Crisis Team from the Kent and Medway NHS Social Care Partnership Trust (KMPT).

The jury in the inquest held at County Hall in Maidstone, which took place last week, heard that Ms Challis was admitted as an informal patient to the Foxglove Ward at St Martin’s Hospital in Canterbury on April 21, 2022, following overdoses and self-harm attempts.

While there, she self-harmed, including swallowing objects. She was later detained for treatment under the Mental Health Act on June 23 the same year following further incidents.

On July 5, she was transferred to the Chartwell Ward at Priority House, under the care of KMPT to enable her to undergo Electroconvulsive Therapy (ECT) sessions.

During her time on the ward, she continued to self-harm, including incidents where she swallowed objects –particularly when she was feeling anxious.

Once the ECT sessions were complete, there were discussions about discharging her.

The inquest heard that these discussions made her anxious, and there was a lack of a structured care plan in place for her return into the community.

On August 11, after a discussion about her discharge, Angie had swallowed items from the ward which had blocked her airway and as a result she turned blue.

She received back slaps and abdominal thrusts from staff and was able to dislodge the item.

Despite this, she was not placed on intermittent observations (one every 15 minutes) until the next day, and there was no risk assessment recorded or review carried out relating to the change in her observations.

Despite the move, there was no evidence that she was observed for a period of almost 10 hours. On August 15, there was another meeting about her potential discharge.

Ms Challis’s daughters Carley and Jade expressed their concern about their mum returning home without receiving the support she required to keep her safe. The escalating risks, anxiety over discharge and self-harm incidents were not commented upon.

Later that day Angie placed an item in her mouth but removed this following a discussion with staff. Despite this, her level of observation was not upgraded from intermittent to one-to-one.

A further incident on August 18 ultimately led to her death.

At about 6pm, Ms Challis was observed to be pacing the communal corridor – a known indication that she was anxious and likely to experience a panic attack.

Shortly afterwards she would be found choking on a teabag that she had swallowed.

Despite staff responding with back slaps and abdominal thrusts, the item had blocked her airway and she became unresponsive. An ambulance was called and the paramedic was able to remove the items from Angie’s throat.

Although she began to breathe again, her condition deteriorated, and she later died on August 22 following the removal of life support.

Her cause of death was given as a hypoxic brain injury.

“We were distressed to discover that despite numerous swallowing incidents, mum had not been risk assessed or placed upon the appropriate level of observations...”

At the end of the four-day hearing, the jury ruled Ms Challis’s death as misadventure, adding that there were failures in her care that directly lead to her death, including:

1.Insufficient information provided to staff to ensure adequate care.

2.Not sufficiently observed due to lack of staff

3.Failure of acceptable support to Ms Challis in relation to discharge anxiety

4.Defective assessment and documentation of risk assessment relating to Angie’s risk of self harm and triggers for exacerbation of her mental health

Carley McNamara, Ms Challis’s daughter said: “Both myself and my sister Jade miss our mum so much and her beautiful smile.

“During our childhood she always provided us with the care and support we needed. Our mum always made us laugh and was always singing.

“She loved those around her endlessly. She had such a strong relationship with her grandson.

“When my mum was admitted to hospital it was such a difficult time for all of us.

“However, we were sure that she would be get the care that she needed. Since my mum was told that she had ‘Treatment Resistant Depression’ she felt that she would never get better.

“I know that mum was worried about being discharged into the community again.

“The safety of those we care for is our utmost priority and we recognise that we fell short on this occasion...”

“We were distressed to discover that despite numerous swallowing incidents that my mum had not been risk assessed or placed upon the appropriate level of observations.

“We really do hope that changes are made so that no other family has to experience the devastating pain and loss suffered by our family.”

A spokesman from KMPT said that it offered “deepest condolences and sincere apologies” to Ms Challis’s family.

“The safety of those we care for is our utmost priority and we recognise that we fell short on this occasion,” they added.

“We immediately undertook a thorough investigation to identify where improvements could be made to better safeguard our service users.

“We acted swiftly to address the issues this found, particularly with regard to staffing and the sharing of pertinent information.

“We will now carefully consider the coroner’s findings and ensure that any further improvements are made.”