A health trust has reviewed its practices and made improvements after a clever and adventurous woman died because of failings in her care.

Rebecca Farmer, 48, was in The Little Brook psychiatric hospital in Bow Arrow Lane, Stone, for almost a year.

She was discharged on February 15 this year without the correct procedures, she was not checked on, and left to administer her own medicine. She died two days later.

During an inquest in August at Archbishops’ Palace, Maidstone, assistant coroner Kate Thomas recorded a narrative verdict.

Ms Farmer died from an unintended poisoning from clozapine.

She had taken an excessive amount, having been discharged with a week’s supply of the drug and no guidance on how much to take.

The coroner told the Kent and Medway NHS and Social Care Partnership Trust to come up with a detailed plan which would avoid similar deaths in the future. That plan has now been presented to and approved by the assistant coroner.

Rebecca’s mother Susan Farmer, of Conifer Drive, Meopham, said: “What they’re doing is what they always used to do and should have done for Rebecca but it’s whether they keep it up.

“It can’t bring her back, but hopefully it will save someone else’s son, daughter, mother or husband.

“If these measures ensure people do their jobs properly Rebecca’s death won’t be in vain.

“Mental health is the Cinderella of the NHS. There’s been no new drugs or treatment for years, since before Rebecca’s problems began. There’s not enough research and people don’t like to talk about it, they look at it as if it’s something scary but it’s just an illness like any other.”

For 23 years Rebecca suffered from a schizoaffective disorder, and went through periods of extreme mental health breakdowns. Over the years, she was in and out of mental health wards 14 times.

She admitted herself into The Little Brook.

Mrs Farmer, 73, said Rebecca would hear voices in her head constantly: “She was convinced it was God speaking to her, cursing her and telling her she was a dreadful person. You can’t imagine what it must have been like to live with that. Sleep brought her no reprieve either.

“She was no danger to anyone but the voices never left her alone.”

Normally after a discharge, a crisis team would come out and administer the right amount of medication, but this did not happen and Rebecca had no idea how much she should be taking.

She was put in accommodation she’d never been in before at in Stanley House, Chatham, which frightened her, and she suffered a psychotic episode that night.

She called the police saying she had hurt people in Canada, despite never having been there.

Mrs Farmer said: “The police called the crisis team but still no one came out to her. The next morning she was found dead.”

Rebecca Farmer was a young woman like any other until she became suddenly gripped by mental illness.

She has a brother and sister and as a teenager used to love to travel to Whitstable to go windsurfing.

In a tribute from her family they described her as a kind and adventurous person.
Music was her life and at 18 she went to study the subject at university in Leeds but that is where her troubles began.

She started to get ill and after a few weeks her mother Susan and father Geoff had to bring her home.

She made a recovery and worked in London as a PA for a while but soon the problems returned.

Mrs Farmer said: “She always wanted to have a career, she hated being on benefits, but she just wasn’t well enough.

“In between periods of illness, she worked. She had several jobs over the years, was involved with the Edinburgh Fringe festival for a time and worked at Brands Hatch.

"Rebecca lived all over the country, in Devon, Leeds, Scotland, and London.

“Rebecca also did a degree in photography at Rochester College of Arts later on. She was so proud to have gone back to study and finish a degree.

“She got a first. She was a very clever girl.”

A spokesman for Kent and Medway NHS and Social Care Partnership Trust said: “We would like to express our deepest sympathies to all those affected by this tragic event and express our condolences to the family of Rebecca Farmer.

“We would also like to reassure Rebecca’s family that our plan of action, following the incident, will be kept in place until all the actions are embedded in our systems.

“Instances of this type are thoroughly investigated in order to ensure we learn the lessons to help prevent anything like this happening in the future.

"One of our main actions is to utilise a discharge tool across our in-patient wards to ensure that safe discharge planning is at the forefront of clinician’s minds at all times. “

The Kent and Medway NHS and Social Care Partnership Trust report compiled by Sarah Holmes-Smith, a mental and general nurse employed by the Trust, noted concerns which were raised by the coroner.

Ms Holmes-Smith conceded that the family’s concerns over medication compliance were not acted on and there was no proper risk assessment for the discharge.

Communication also broke down between the trust and various other relevant bodies, the Crisis Resolution and Home Treatment team (CRHT), the Medway Council’s social work team and the Community Mental Health Team (CMHT).

New steps have been taken to improve the situation.

KMPT carried out a Clinical Serious Incident Learning Review and has instigated the following changes:

• Sanctuary Housing (run’s Stanley House) has been spoken to and now all relevant care groups are to be invited to discharge planning meetings.
• The Trust has started emailing the Medway Social Work team when a patient is admitted to a KMPT ward, so they can keep in touch, attend review meetings and check their responsibilities to the patient.
• A Medway Council social worker was found to have records of contact made at Stanley House, but this information was not available to KMPT. Now, information is to be better shared and social workers will also have access to add notes to KMPT’s electronic records when they have had contact with a patient or taken steps with discharge planning.
• A “Count down to discharge” tool is being rolled out with a checklist which must be completed before a patient can be discharged.
• The Care Programme Approach (CPA) documents were found to not be patient centred enough and the risk assessment not fit for purpose. Nurses have had extra training to improve the quality of them and a group has been set up, the Care Planning group, to devise and implement improvements.
• The crisis resolution and home treatment (CRHT) operational policy has been revised so they are more involved in getting the patient back into the community.
• The crisis (CRHT) teams were found to have too many other tasks added to their jobs, which is having a bad impact on basic patient care.
• KMPT is now separating some of the services expected of the team to create a ‘pure’ home treatment team with a clear role.
• A daily teleconference call between the Community Mental Health Team (CMHT) and crisis (CRHT) to discuss all patients on the wards has been set up.