The ex-husband of a Luton woman found drowned in a brook claimed she was let down by “ineffective” mental health services at her inquest last week.
55-year-old Jacqui Simmonds was found in the brook off Mill Lane in Tempsford on February 1 after being reported missing the previous day.
A post-mortem found several prescription drugs in her system.
On January 29, Mrs Simmonds, of Wadhurst Avenue Luton, had gone “desperately” into A&E seeking help.
A serious incident review after her death found that the nurse who carried out her assessment failed to check the new electronic system which would have revealed Mrs Simmonds had attempted an overdose at a private psychiatric unit in Oxford three days previously.
Retired air hostess Mrs Simmonds was accompanied to A&E by her elderly mother – who was unaware of her daughter’s previous suicide attempt.
At last Thursday’s inquest at Ampthill, Mrs Simmond’s husband of 25 years Peter was visibly moved as he heard the details of his ex-wife’s attempted overdose on January 25.
He said: “It’s awful. I didn’t know any of it. This is the first time I’ve heard about it at all.”
The doctor who interviewed her after the attempted overdose reported that Mrs Simmonds didn’t wish her mother to be informed and that as she was willing to engage with the crisis team in Luton, there weren’t grounds to breach confidentiality.
Mr Simmonds said: “I saw her GP and he didn’t know anything about it and I think it’s disgraceful. I think the crisis team was disgraceful. I think its ineffectual, it just doesn’t work.”
A serious incident review was carried out by mental health nurse Paul Rake on behalf of East London Foundation Trust – the authority responsible for mental health services in Bedfordshire. His report highlighted a number of care delivery problems and service delivery problems relating to Mrs Simmonds’ treatment.
Mr Rake said: “The crisis team was greatly affected and they found it a traumatic outcome.
“When I met with her nephew Mr Hayes, he said that she had noticed that two of the staff who had left the house were laughing and she thought they were laughing at her. I couldn’t find any evidence to suggest that that was the case.”
The coroner then requested future confirmation from the trust that the review’s recommendations are undertaken. He told Mrs Simmond’s husband: “It’s important that not only is East London Foundation Trust learning the lessons, but we as the public are seeing that.”
In a tribute to his late wife, Mr Simmonds said: “Jacqui was the most fantastic person in the world,” before breaking into tears.
“She had a hysterectomy and I think that affected her quite badly. Since then it was picking fault with everything, she left me and was looking for something that she was never going to get and it’s a very sad end.
“I think the drugs are bad as well. It seems to me as soon as you go on drugs you want to commit suicide.”
Another family member added: “She was very glamorous and lived life to the full. The way she conducted herself, she was always encouraging of other people, even complete strangers.”
Concluding the hearing, assistant coroner Ian Pears said: “For me, I have to be close to 100% sure about suicide. I don’t think there is sufficient evidence here for me to be persuaded that this was suicide. That doesn’t mean it wasn’t – only she knows that.
“As a result I will find accidental death. That’s the finding I’m going to make in terms of the law.”