Could my daughter have been saved - did she slip through the net?

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A Lancashire teenager battling complex mental health issues was tragically unable to beat a dangerous substance addiction before her untimely death, an inquest heard.

Keira Cowley, 18, who was known as Levi Proctor, died in a wooded area off Carr Lane, Kirkham, on September 21, 2023.

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She had been struggling with a diagnosed emotional unstable personality disorder, which included extreme mood swings, complicated by her addiction to solvents.

The teeager had previously spoken of taking an overdose of paracetamol.

A pathologist's report found the cause of death to be anoxia (shortage of oxygen to the brain), caused by inhalation of butane gas.

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The inquest, led by the Assistant Coroner for Blackpool and Fylde, Louise Rae, began at Blackpool Coroner’s Court on Monday and continued today.

The inquest into the death of 18 year old Keira Cowley - known as Levi - continued todayThe inquest into the death of 18 year old Keira Cowley - known as Levi - continued today
The inquest into the death of 18 year old Keira Cowley - known as Levi - continued today | Third party

Levi’s mother, referred to as Mrs Proctor at the inquest, attended the hearing by video link.

She questioned whether her daughter had capacity to make decision because of her condition, and asked whether she should have been admitted to The Cove, a unit in Blackpool for young people with serious mental health problems.

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She asked; “ Did my daughter slip through the net? Could she have been saved?”

Levi, of Preston Street, Kitkham, had been under the care of Lancashire & Cumbria’s NHS Health Trust’s child and adolescent mental health services(CAMHS), who were aware of her complex issues.

However, in the weeks before her death, she had been transferred to the Trust’s Adult services upon reaching her 18th birthday, and this had required a careful period of transition between the two teams.

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A complex young person

Katherine Pearson, a social worker with the CAHMS service who had been working closely with the teenager before her transfer to adult services, said: “Levi was struggling with her emotional regulation, she was a complex young person whose responses could be quite reactive.

“She was quite hard to reach, generally, and her engagement was on a surface level - she told professionals what she thought they wanted to hear.”

Mrs Perason said Levi hs been prescribed antidepressants but they were having no effect on her mood swings.

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It was decided that an alternative treatment known as DBT -Dialectical Behaviour Therapy - based on cognitive behavioural therapy for  patients with intense emotional struggles - would be more appropriate.

Blackpool Coroner's Court at the Town HallBlackpool Coroner's Court at the Town Hall
Blackpool Coroner's Court at the Town Hall | National World

However, it would require the patient to be clear of any kind of substance abuse in order to work - and Levy was still using solvent, despite expressing desire to stop.

Ms Pearson said: “She knew there was a high risk of death if she continued to use solvents.”

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The inquest was told, despite concerns about the solvent use, Levi didn’t meet the threshold of needing to be detained and told practitioners that she thought the crisis was over.

Corner Louise Rae asked if the teenager has the capacity to understand the actions she was taking?

Ms Perason said: “Yes. Capacity did vary but I did discuss the solvent abuse and she did demonstrate understanding. She had moments of madness, where she would make unwise decisions and then regret it.”

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Did she know the risks of using solvents?

In a question to Ms Peaeson, Levi’s mother - Mrs M Proctor - asked if her daughter had capacity to make decisions about the help she needed, given her diagnosis. Did she know the risks of solvent abuse?

She asked if her daughter had slipped through the net and whether she should have been admitted to The Cove, a residential unit for young people suffering from mental health problems.

Ms Perason replied that Levi did know the risks and did have capacity, although this did fluctuate.

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She said that, unfortunately, when Levi was most in need of help, that was the time she did not ask for it and was harder to reach.

In early September, Levi’s case was transferred over to Adult services, who only had a short time to get to know her before her death,

Philip Robinson, a registered mental health nurse who was a manager for the Preston East mental health team, was asked by the coroner how the transition between the two services had gone.

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He replied: “We had already been told she was approaching the age of 18 and identified that she would continue to require mental health support - so it was not an abrupt transition.

“The practitioners who met her tried very hard.

“We received referrals, I requested an invitation with the consultant and had some very fruitful meetings.”

Asked what his experience of solvent abuse was, given it was not a usual case, he said: “Yes, it;s very uncommon in my experience, it is a type of substance abuse which is very rare.”

The coroner ased: “Did it require special training?”

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He replied: “We have contact with Aspire - they are the experts and we could call on them.”

The team had also looked into DBT treatment for the teenager but there was a waiting list of 30 weeks for psychiatrists to be available to undertake the sessions.

Another barrier was Levi’s continued substance misuse

The inquest heard again that the treatment would require her to abstain from solvent use, but she was still using it and that solvent use “would have to be addressed.”

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Could daughter have been saved?

The court heard from Rusell Moretta, a registated mental health nurse with the Lancashire ans Cumbirua NHS Foundation Trust, who carried out an  investigation into Levi's; death and what had contributed to it.

He said: It was ackowowled that the transition was not going to be straightforward and it considered how best to do it.

“There was a gathering of information from CAHMS to make it a smooth transition.”

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The corner asked: “Admittedly, the service did not have a long time, was everything done in that time, that could have been done?”

Mr Moretta replied: “Yes - it was a short period of time and that final period is focused on understanding the information given, and looking at the treatment options and getting to know Levi as a patient.

“If I;m honest, I find it difficult to see what we could have done differently.”

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The coroner asked if it was possible to have  emotional unstable personality disorder and have capacity to make decisions.

Mr Moretta repelled: “Yes, it doesn't necessarily mean you don;t have capacity - it does fluctuate.”

Asked by Mrs Proctor is he though her daughter could have been saved, he replied: “That’s very difficult question to answer - it depends on the care and treatment she received.”

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He added: “I think she was with the appropriate team at the time - the number of professionals and the package of care was really robust.”

The corner, Ms Rae, said she did not wish to rush her decision over the verdict, and adjourned the hearing for the next day - Thursday September 20

Proceeding

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