A VULNERABLE Hampshire woman plunged to her death just moments after paramedics, who had been alerted to her suicide threat, left her alone in her flat.
Jacqueline O’Neill died from multiple injuries after falling from the balcony of her third floor flat at Parmiter House in Wales Street, Winchester.
Winchester Coroner’s Court heard that the 54-year-old jumped just three minutes after the paramedics had left her flat, on September 30.
Ms O’Neill had been under the care of Southern Health NHS Foundation Trust’s community mental health team.
The inquest heard that paramedics frequently attended her flat and she had had taken an overdose two weeks before her death.
On the day she died she told the community mental health team and paramedics she was in crisis.
Ms O’Neill first sought help from the the mental health team was was allegedly advised to “take some diazapam and have a cup of tea”.
She refused and immediately called the ambulance service, who arrived quickly as she was deemed a suicide risk.
The inquest heard evidence from paramedics Alison Gamlyn and Simon Marchant, who spent more than 90 minutes with Ms O’Neill.
The paramedics offered to take Ms O’Neill to the Royal Hampshire County Hospital where someone from Melbury Lodge mental health unit would meet her there, but she refused.
They then agreed that a member of the community mental health team would speak to Ms O’Neil.
The inquest heard Mr Marchant left a message for the team, but did not include his phone number.
Mr Marchant later spoke to a member of the community mental health team, and said he he not been told of Ms O’Neill’s previous suicide attempts.
The court heard Miss O’Neill’s demeanour appeared “brighter” to the paramedics and they left.
When asked about Miss O’Neill’s suicidal remarks, Mr Marchant said: “It did not seem like a serious threat, it was like a throw away comment.”
Just as the paramedics were about to drive off, witness Kay Tyson told them she had seen Ms O’Neill fall from the balcony.
They rushed to treat Miss O’Neill but she died.
The inquest heard Miss O’Neill suffered from mixed personality disorder and alcohol dependency.
Speaking on behalf of Southern Health NHS Foundation Trust was psychiatrist Dr Cory de Wet, who admitted that Ms O’Neill did need a social care assessment and was a “suicide risk”.
Senior coroner Grahame Short recorded a verdict of suicide.
Mr Short said there was no clear plan in place for Miss O’Neill and said the suicide was likely to have been an “impulsive act”.
He did not criticise the ambulance service, and said one of the key factors was the lack of a “support network” for Ms O’ Neill.
Mr Short said: "I believe it was an impulsive act I do not believe it was something she had planned for any length of time but given her history I do find that she did want to end her life.
“After the ambulance crew had left she was on her own again she realised she was in the same position as when they (the ambulance crew) arrived - there was no solution to her problems.”
A spokesman from South Central Ambulance Service said: “As noted by the coroner, the care and advice provided by the ambulance service to Jacqueline was appropriate and there were no failings of the Trust or its staff. The Trust extends sincere condolences to the victim’s family.”
Dr Cory De Wet, clinical service director for West Hampshire for Southern Health said: “The team supporting Miss O’Neill were deeply saddened to hear that she had died and I extend my condolences to Miss O’Neill’s family at this difficult time.
“At her last meeting with the treatment team a tailored care plan was agreed to address her needs and care preferences and this is something her care team was developing.
“We have completed a full investigation to see if there was anything we could have done to improve the care we provided and this has been shared with Miss O’Neill’s family.
“As part of our efforts to improve care we have recently developed a new policy for supporting people experiencing both mental health and substance misuse problems.
“We continue to work alongside other agencies to better join up our response to people accessing multiple services.”
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