Woman who lost brother and mum in mental health battle devastated as coroner rules NHS failures did not cause tragic deaths

A woman who lost both her brother and her mum within a month of one another says she feels ‘angry, upset and frustrated’ after a coroner decided failures in their mental health care could not be definitively linked with their tragic deaths.

Saturday, 27th November 2021, 4:55 am

Holly Ireland’s 17-year-old brother, Marshall Metcalfe, died on May 7 2020 after falling from the roof of the Sainburys superstore on Talbot Road, Blackpool.

Just one month later, on June 7, Ms Ireland, 44, died at her home on Heeley Road, St Annes, from the combined effects of a large dose of methadone, fatty liver disease and bronchial pneumonia.

Both mother and son had been suffering from schizophrenia and had been under the care of the Lancashire and South Cumbria NHS Foundation Trust mental health services in Blackpool.

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Marshall Metcalfe with mum Jane Ireland and sisters Macy and Holly

An independent investigation found that ‘opportunities were missed’ in Marshall’s care, while Lancashire social services admitted there had been a serious communication lapse between departments.

However, following a two-week inquest, coroner Alan Wilson ruled that it could not be proved that these failures directly caused Marshall and Jane to die when they did.

READ: Mum and son’s deaths not directly linked to missed opportunities, coroner ruled at inquestHolly, 26, said: “It was very disappointing, in the end. Throughout the whole hearing there was so much said about the failures in their care - even more than I imagined there would be.

“People didn’t do things they should have done, or they didn’t know the things that they should.

“I still can’t wrap my head around it. For it to just end like this is so frustrating, and I feel like it’s just another example of the system failing mentally ill people.

“I’m angry, upset and frustrated, because to me it’s so obvious that the people who should have been helping my mum and my brother missed all the warning signs. They should have been safeguarded, and they weren’t.”

Jane, a mum of three, was described by her family as ‘a fun and loving person who brightened every room she walked into.’

“She was a talented makeup artist and worked in theatre productions and photoshoots. She was also a qualified Reiki therapist and dreamed of opening her own retreat,” they said.

However, she had suffered from mental health problems since 2010, when she was viciously attacked by an abusive ex-boyfriend.

She moved from Burnley to St Annes with her children in search of a new life. But her mental health continued to deteriorate 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, drinking excessively and neglecting her antipsychotic medication.

Marshall’s mental health, meanwhile, dramatically declined in 2018 and he had two lengthy spells in The Cove unit in Heysham for children 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.

Holly said: “My mum rang the doctor in December (2019) and said she was hearing voices and really struggling, and then they released Marshall into her care in January. It was the worst possible thing they could have done because neither of them were stable. It wasn’t safe at all.”

She added: “The system is broken and has failed me yet again after so many instances over the last decade. These have been the hardest times of my life and I don’t feel that anybody else has should ever have to go through what me and my family have, but sadly this is becoming the case for far too many - not just on this country but around the world.

“I believe it shows that the system is corrupt at its core and not there to genuinely care for people.

“I do however take some positive in how much light the inquest has shed on the failures in the current system. I will continue to fight against it for my loved ones and for all other people out there who have been through or are going through grief at the hands of the mental health system.

“I still have a lot to process, but this is not the end of my fight to change this broken system we are all currently subject to. I will be pushing to further the cause and hoping in future to link with other families going through this who are fighting the same fight.”

Lucy McKay, a spokesman for INQUEST, a charity representing bereaved families, said: “Time and time again we see families’ concerns being ignored, and mental health and social services failing to communicate and provide holistic support. These are the fundamentals of care for anyone with mental health or support needs.

“To see a family lose both a son and a mother due to these kind of basic and well documented issues is as tragic as it is deeply frustrating. We must see national action and investment in mental health and local services to enable joint up support. While professionals need to create a culture shift towards listening to family advocates like Holly, so people are no longer forced to fight for their family’s lives.”


Marshall, a Lytham High School pupil, was known to social services. However, when he was sectioned in the children’s mental health unit at The Cove, social services did not remain involved, and no arrangement was in place when he left.

Following the inquest, which handed down a conclusion of suicide in Marshall’s case, Coroner Alan Wilson announced his plans to write to minister Gillian Keegan at the Department of Health and Social Care, in the interest of preventing further deaths.

The court heard that when Marshall left The Cove on 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 in his discharge.

A lack of communications between the social service and mental health teams meant that Ms Ireland’s deteriorating mental health was not flagged up.

Holly had raised concerns that her mum was not well enough to look after Marshall because of her own mental health problems. However, no alternative accommodation for Marshall was sought, as he came from a loving home.

In a statement, his family said: “(Marshall) loved football and supported Burnley FC. He also enjoyed fishing and gaming. He was a fierce and loyal friend. We are heartbroken that we will never see him grow up and fulfil his dreams.”

Holly added: “While I am glad that this report is being made, I still can’t say I’m at all happy with the inquest’s outcome.

“No preventing future deaths report has been carried out with regards to the car park where Marshall died. We heard from a council representative that they made Sainsbury’s aware of the dangers from 2017. Yet it took until 2020 and Marshall’s death for permanent barriers to be put up. The council representative told the inquest that they have no power to compel private companies take any steps to make known suicide hot spots safer. This lack of regulation puts future lives at risk across the country.”

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