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A mother took her own life while three of her key mental health support workers were on holiday at the same time.
Gemma Hutchins died at Maidstone Hospital in Hermitage Lane on April 18, 2018, after taking an overdose of prescription tablets.
Mrs Hutchins, of Abbots Field, Maidstone, sent her husband Steve a suicide note by email on the day of her death.
The former design engineer rushed home to find his wife "dazed" and rang the ambulance service at around 2.30pm, who arrived just under 30 minutes later and took the mother to hospital.
The paediatric nurse suffered five seizures as a result of the overdose and went into cardiac arrest. She died later that evening.
Her cause of death was given as consumption of an antidepressant, as well as depression and obsessive-compulsive disorder.
A two-day inquest into her death heard she had been battling mental health issues in her adult years and had been diagnosed with severe depression.
It was also revealed the 32-year-old had previously tried to take her own life on a number of occasions, including an attempted overdose on March 23, three weeks before she died.
Assistant coroner Sonia Hayes explained how the mum was seeking professional help which she was engaging with.
Three of the main professionals she was seeing included psychotherapist Hayley Brookes, KMPT care co-ordinator Wilson Banda and her GP at the Blackthorn Medical Centre Dr Mark Reynolds.
The inquest heard how Mrs Hutchins was having monthly visits from Mr Banda and members of the mental health team but this was increased to weekly meetings following her overdose in March as she was a "high risk".
However, in the week of her death all three of her key contacts were on holiday or taking leave.
"I think she took actions as a result that she had lost faith the mental health services could help her."
It was arranged by Mr Banda that Sue Stoneham, a support, time and recovery worker for the KMPT mental health team, would be in contact with Mrs Hutchins while he was away.
The court heard from Ms Stoneham who met with Mrs Hutchins on April 5 and was meant to contact her a week later by phone.
However, the mental health worker, who has 23 years experience, failed to call her due to an "over-running" appointment and also failed to make a follow-up phone call to explain why she was not able to call Mrs Hutchins or arrange another check-up.
This meant Mrs Hutchins went nearly two weeks without contact from any support workers at a time when her care co-ordinator had changed her monthly visits to weekly due to concerns for her.
Speaking at the inquest, her husband Steve said he felt this missed contact contributed to his wife's death.
"She did want to get better, she had lots of future plans."
He said: "She had many periods where she felt down.
"I think she took actions as a result that she had lost faith the mental health services could help her.
"She did want to get better, she had lots of future plans."
The coroner explained she did not think the missed actions contributed to Mrs Hutchins' death, as she had a history of suicide attempts and the court had heard how the mother had written blog posts for her children on important future dates, such as their 18th birthday and wedding day, which showed she had planned to take her life before.
However, Ms Hayes said it was "unfortunate" the missed contact happened and could have led to Mrs Hutchins feeling "abandoned" by the services.
As a result, the coroner made a section 28 ruling and explained she would be writing a report to KMPT about the events leading to the mother's death.
Mr Hutchins raised another concern during the two-day hearing where he explained how on March 23, after being discharged following her overdose, his wife was prescribed drugs she used for the overdose that hospitalised her which would later be used to take her own life.
However, again, Ms Hayes said the Trust acted correctly and she did not think this contributed to the mum's death as evidence given by Dr Reynolds described a similar situation where he said if her medication was taken away from her it could have made the situation a lot worse.
The inquest heard from consultant psychiatrist Vincent Mtika, who was working at Albion Place Medical Practice at the time and was treating Mrs Hutchins, about how there was some suggestion she had Emotionally Unstable Personality Disorder, which she was never formally diagnosed with.
He explained how the disorder can lead to some people becoming "impulsive and anxious" as well as heightened fears of rejection and abandonment.
The court heard how this potential diagnosis was a concern for Mrs Hutchins, who was previously a health visitor, as she thought it could affect her aspirations of returning to full-time work.
In her conclusion, Ms Hayes said the death was "sad and tragic" and it was clear Mrs Hutchins had "significant family support", before ruling her death as suicide.
A spokesman for Kent and Medway NHS and Social Care Partnership Trust said: “We are deeply saddened by the death of Mrs Hutchins and our thoughts are with her family and friends.
“We have shared with Her Majesty’s Coroner existing procedures to enforce the need - to our staff -to follow the existing buddy system which helps to ensure the ongoing safety of our patients during periods of staff absence.
“Where escalations are made or concerns are heightened, our teams always monitor via a daily morning review meeting and discussions with a designated senior clinician. These are important measures which are in place to minimise risk and keep those who use our services as safe as possible.
“We will contact the family with an open invitation to meet and discuss any outstanding questions or concerns to ensure they are answered.”
The inquest was attended by Mrs Hutchins' husband Steve, her aunty Sarah Murray and her mother, Stephanie Markiewicz and step-dad Kris Markiewicz, who lost their son and Mrs Hutchin's brother 16-year-old Joe in February after a sudden brain haemorrhage.
If you need help on an emotional issue you can call the Samaritans free, at any time, on 116 123.
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