Mum and son’s deaths not directly linked to missed opportunities, coroner ruled at inquest
A coroner has accepted that there were some missed opportunities to help a mother and son who died within a month of each other after they had both suffered with serious mental health problems.
But Andrew Wilson said he could not say conclusively that any issues with the way professional duties had been carried out had effectively caused the lives of Jane Ireland and her son Marshall Metcalfe to be shortened.
Marshall, 17, of Heeley Road, died on May 7 2020 in Royal Preston Hopsital from massive injuries after falling off the roof of Blackpool’s Sainsbury store.
Just one month later, on June 7, Ms Ireland died at the home she shared with her son from the combined effects of a large dose of methadone, fatty liver disease and bronchial pneumonia.
A verdict of suicide was recorded in the case of Marshall, after the inquest heard that he had made his way to the top of the building, climbed past barriers and allowed himself to fall after climbing onto a wall.
However, a narrative verdict was recorded in the case of Ms Ireland, as the coroner could not conclude that she had intended to take her own life.
Ms Ireland died after injesting methadone but she was also suffering from fatty liver disease and bronchial pneumonia.
The pair had both been suffering from schizophrenia and had both been under the care of the Lancashire and South Cumbria NHS Foundation Trust mental health services in Blackpool.
An independent investigation carried out before the inquest found that, although many aspects of Marshall’s care had been ‘adequate, if not excellent’, ‘opportunities were missed’ to help him.
Lancashire social services were also involved and admitted lessons had been learned after a serious communication lapse between departments.
Jane Ireland was described as talented theatrical make-up artist and a loving mother of three.
Marshall had been a popular pupil at school, keen on sport, coping well in class and with lots of friends.
But Ms Ireland’s mental health issues were linked back to 2010 after she was subjected to vicious domestic abuse which saw her partner bite her nose off, which required several operations and shattered her mental wellbeing.
Despite moving from Burnley with her children to a new life in St Annes, her mental health gradually deteriorated further and she was eventually hospitalised after two drug overdoses.
A year before her death she was hearing 13 different voices in her head, including that of the God Yarweh and there were concern she was drinking to excess and not taking her antipsychotic medication.
Marshall’s mental health, meanwhile, had begun to dramatically decline two years begore his death and he had two lengthy spells in The Cove unit in Heysham for children and adolescents with complex mental health needs, the final stay lasting from February 2019 to January 2020.
During Marshall’s lowest point in The Cove in the summer of 2019, his ability to communicate had deteriorated and he was making grunting noises and rolling around on the floor.
One issue that caused concern was that social services were no longer involved in Marshall's care when he entered The Cove and no social care arrangement was in place when he left.
Mr Wilson said he was concerned that social services had not remained involved in his care after Marshall was admitted to The Cove and he intended to send a Prevention of Future Deaths Report to Gillian Keegan, the Minister of State for Care at the Department of Health and Social Care.
When he left The Cove in January 6 2020, the team at the unit believed his mother was the best person to care for him but believed social services should have been involved apart his discharge.
The inquest heard that a lack of communications between the social service and mental health teams of Ms Ireland and her son had meant that her deteriorating mental health was not flagged up.
Marshall’s sister Holly had raised concerns that her mum was not well enough to look after Marshall because of her own mental health problems.
But the coroner raised the point that no alternative accommodation for Marshall appeared to be available and that he came from a loving family.
Marshall's health had not deteriorated upon his discharge and he appeared to be taking his medication.
Holly Ireland said she would consider the full outcome of the inquest before making a statement.