The family of a young mum who tragically died at home after taking an overdose have paid tribute to her, and say she was 'let down' by mental health services.
Dari-Anne Sawyer, 23, sadly passed away at her Teesside home in on April 12, 2021. An inquest heard how she told a clinician that day that she had taken an overdose, and would go to hospital once she had arranged childcare. Her devastated loved ones say they can't understand why they weren't contacted, and she was then left alone with her two young daughters.
Paying tribute, Luke Baker, father of her two children, said: "She was a truly lovely person - kind, beautiful. She loved her kids so much," reports TeessideLive.
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Step-dad Eric Holmes told Teesside Live following the inquest: "I just feel like she was let down by the trust. Why did they leave her on her own that day when they knew what was going on in her head. They could have rang any one of us and we would have been there for her.
"The reason why we are so annoyed is because they left her on her own with two kids in the house - they could have rang their dad. But it was left for us to go and find her. We didn't know until we got to the house and asked the police to open the door."
However, the coroner found the mental health professional took the appropriate action and there were no contributing factors to her death.
Dari-Anne was reported to be "quite quiet" when the clinician visited her at home on April 12 last year and it was towards the end of the appointment that she explained she had taken an overdose the previous afternoon while her children were out. The resumed inquest, which took place at Middlesbrough Town Hall, heard Dari-Anne had said she had no ill effect other than a stomach ache but the clinician wanted her to be medically assessed.
Giving evidence, Christine Maxwell, a serious incident reviewer at the trust, who was not responsible for Dari-Anne's care, said: "Dari-Anne had said that she didn't want to wait for an ambulance to come and she needed to pick her daughter up from nursery." Ms Maxwell said Dari-Anne told the clinician she would go to the hospital when she'd organised childcare.
The inquest heard how the clinician called the hospital to inform them Dari-Anne would be coming to A&E and to ensure she would be checked over on arrival and be reviewed by the psychiatric liaison team. The clinician then spoke to the crisis team and called to speak to Dari-Anne again to tell her they'd arranged for her to attend the hospital.
Ms Maxwell added: "An hour after that they rang the hospital to check Dari-Anne had arrived and was told she had not at that time. They tried to ring Dari-Anne back but there was no answer."
Concerns were raised among her family and step-dad Eric called the police but Dari-Anne was tragically found dead at her home. A post mortem examination, conducted by Dr David Scoones, concluded Dari-Anne who was born in Stockton, died as a result of hanging.
Since the TEWV's serious incident review (SIR), standard operating procedures have been implemented, in line with NICE guidelines, to make sure the appropriate guidance is in place for clinicians if someone has taken an overdose.
"The clinician has been concerned for Dari-Anne, they tried to get her to call an ambulance, [Dari-Anne] said she was going to call family members," said assistant coroner Karin Welsh. "They checked with A&E and rang Dari-Anne afterwards. Hindsight is a wonderful thing. The clinician on that occasion acted appropriately - that's not to say with hindsight she wouldn't have done things differently."
'She didn't mean to do it'
The inquest heard how in February, six weeks after the birth of her second daughter, a call was made to the crisis team by mum Katharine Sawyer, who said Dari-Anne was having thoughts of harming herself. Dari-Anne, who had previously been diagnosed with emotionally unstable personality disorder, was taken to A&E where she was assessed by a psychiatric liaison team where she explained she'd been struggling and a plan was put in place to look at a referral to impact services.
Ms Maxwell explained that, as part of the SIR learning, the trust had looked at how referrals were made with regards to the February hospital visit. After coming to A&E, a referral was made with the Impact team and for Dari-Anne's medication to be reviewed with her GP.
Ms Welsh asked if this was left for Dari-Anne to follow up and Ms Maxwell said the review looked at how they could have supported Dari-Anne in making that referral with the Impact service. It also considered when conversations should be had with the perinatal community mental health team and if support would have been appropriate for Dari-Anne, who was later referred by the health visitor.
"Obviously back in February, perhaps what happened when she went to A&E could have been handled differently. I have to look at matters that are more closely linked to what happened in April," said Ms Welsh.
Her heartbroken mum Katharine Sawyer told the coroner: "She didn't mean to do it. She would get overwhelmed and her brain flooded up - she would do impulsive things and she always regretted them afterwards."
Ms Welsh made a short form conclusion of misadventure, rather than suicide, as she did not believe Dari-Anne intended to take her life. Training has been carried out in the hospital about the perinatal community mental health time and when referrals should be made - which has seen an increase.
Patrick Scott, managing director of the Durham, Tees Valley and Forensics care group at the Trust, said: “Our thoughts are with Dari-Anne’s family and friends during this very sad time. We found some areas of learning after completing a review of Dari-Anne’s care and treatment.
"While this did not contribute to her death, we are always keen to understand where we can improve. The coroner recognised that the actions of our staff were appropriate during what was a difficult time.”
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