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By Phoebe Fuller
14:04, 28 JAN 2021
Eleanor Lomax took her life in February last year, but an inquest found that she had not intended to die
Barnsley teenager who took her own life did not intend to die, an inquest heard yesterday.
Eleanor Lomax was just 19-years-old when she died and, though she took her own life, yesterday’s inquest at Sheffield ‘s Medico Legal Centre found that Eleanor had not intended the act to be fatal.
The court heard from Eleanor’s childhood mental health nurse, Laura McClure, who is a member of the Barnsley Childhood and Adolescent Mental Health Service (CAHMS).
She told the court that she had first met Eleanor in April 2018, when Eleanor had been referred to her following a suicide attempt.
Mrs McClure told the court that Eleanor had said her mental health struggles had begun in 2012, when she was bullied in secondary school.
She said: “She’d experienced some significant trauma in terms of significant bullying, the loss of grandparents and she had, in her world, a sense that people would leave at some point so she would keep people at arm’s length.
“My goal and Ellie’s goal was to try and improve her ability to make relationships and maintain those, so that they could help to lift her mood.”
Eleanor saw Mrs McClure for regular interpersonal therapy sessions, which was the recommended treatment for depression and anxiety, both of which Eleanor displayed symptoms of.
But it was during their seventh session that Mrs McClure said that it became clear Eleanor would need to be referred to adult mental health services, as she had not made “enough progress” to be discharged and was approaching her 18th birthday.
Mrs McClure said that, during their time together, she did not notice a marked improvement in Eleanor’s depressive symptoms and she told the court that she felt “disappointed in herself” that Eleanor’s symptoms had not lifted.
“Her symptoms fluctuated between moderate to severe to moderate, so they weren’t at a level where I would have been comfortable discharging her from mental health services completely”, Mrs McClure said.
A transition meeting took place on November 8 2018, which is when Eleanor’s care was handed over to the adult mental health service and she began to have regular therapy appointments with an assistant practitioner in clinical psychology, Mr Karl Abbott.
Eleanor’s mum, Elaine, told the inquest that – despite having had a number of appointments with Mr Abbott – Eleanor had not felt that these appointments were helping her.
But Mr Abbott told the court that the last time he had seen her, there had been a “positive progression” and Eleanor seemed more engaged and less anxious.
Despite this, Eleanor had made another suicide attempt on July 31 2019 two weeks after seeing Mr Abbott on July 16, which required treatment at A&E.
Her care was eventually handed over to consultant psychiatrist Dr Patricia O’Malley, at The Priory hospital in Cheshire, where Eleanor was referred in November 2019.
Dr O’Malley told the inquest that Eleanor was referred to her on November 25 and attended an outpatient clinic with her on November 28.
The court heard that Dr O’Malley did a detailed assessment with Eleanor, which was when it became apparent that the teen was using alcohol dangerously and this was having a negative affect on her mental health.
Dr O’Malley said: “She did tell me that she’d been really struggling and she said that she’d been having problems for a number of years, she told me she’d been drinking heavily particularly at the weekend and said she couldn’t remember how much she drank but would frequently blackout.
“She said she was using alcohol because she was socially anxious, so she was aware that she was using alcohol to cover up distressing feelings. She said when she was drinking she frequently got into trouble with arguments or by trying to harm herself.”
Dr O’Malley recalled that Eleanor had told her about an incident the previous weekend, where she had been out drinking with friends and had tried to harm herself.
The court heard that, the following day, Eleanor was “feeling awful” and again attempted to end her life.
“She did not expect to be found, her intention was to end her life”, Dr O’Malley said, “her mother did return and, despite Ellie’s protestations, managed to get her to hospital. She was seen by the mental health team, but she didn’t want to engage with them which was what prompted the referral to us.”
Dr O’Malley told the court that her assessment of Eleanor, when she saw her in November, was that the teenager was “very chaotic” and that alcohol was playing a big part in her symptoms.
She said: “She was using alcohol in a harmful way and had made a serious attempt on her life. I thought she had features of depression and anxiety but also features of an emerging unstable personality, she was only 19 at the time so her personality wasn’t fully formed, but there was an emerging unstable personality.”
It was therefore recommended that, following her initial assessment with Eleanor on December 28, Eleanor be admitted to The Priory as an inpatient that night.
Dr O’Malley told the court: “When Ellie was admitted obviously I had only just met her so, initially, we put her on close observations.
“I did at the very start think that her use of alcohol was very harmful and I thought that she should do our addiction programme and I thought that would be a way for her to engage and look at why she was using alcohol. That’s what I recommended, though I have to say Ellie wasn’t drinking every day and there were no physical withdrawal symptoms, so she wasn’t physically dependant on alcohol.
“I got a message the following day to say that Ellie and her family did not want her to do the alcohol addiction programme, so I had a discussion with them and we agreed that we would change her onto the general programme to look at stabilising her mood.”
The court heard that Ellie’s mood was rapidly changeable and that her symptoms were indicative of an emerging emotionally unstable personality disorder, also known as borderline personality disorder.
Dr O’Malley told the court that she began to see Ellie twice a week, once a week in a one-to-one appointment and once a week with other therapists and ward nurses and doctors.
She said: “I talked to Ellie about her mood and she was very clear that her mood was changeable and she found it very distressing, so we talked about introducing a mood stabiliser called Quetiapine, a 50mg dose.”
Eleanor’s dose of the mood stabiliser was eventually upped to 100mg and, by December, she was telling Dr O’Malley that she felt “well” and was not having any suicidal thoughts, she was also keen to be discharged so that she could return home.
As Christmas was just around the corner, it was decided that Eleanor would go home for a period of temporary leave to assess whether she was ready to be fully discharged or not, so she was due to return to the ward on December 23.
Dr O’Malley said: “When Ellie returned on December 23 she told me that the leave had gone really well and she’d had time with family and friends and was a bit anxious at times but was fine and hadn’t been drinking alcohol.
“But Ellie’s mum gave a very different picture: she said Ellie had been out both nights and they hadn’t seen much of her, that she had used alcohol and when she drunk alcohol it very clearly had an impact on her mood.”
But Eleanor was still keen to be discharged, so it was decided that a second period of leave would be tried over Christmas, with Eleanor due to return to the ward on December 27.
It was at this point that she turned a corner and accepted that alcohol was a problem, the court heard.
“When she returned on the 27th things had deteriorated, she was in a very, very distressed state”, Dr O’Malley said, “she admitted she had been drinking and then said to me ‘I now realise that alcohol is a big problem for me’ and she wants to be back in hospital and to do the addiction programme.”
Dr O’Malley said that Eleanor engaged with the programme and, though she found it especially difficult and very challenging, she was “doing well”.
Eleanor’s medication had also been increased, with her on a higher dose of both mood stabilisers and anti-depressants and she was discharged from the hospital towards the end of January 2020.
The last time that Dr O’Malley saw Eleanor was on January 30, a week after she had been discharged as an inpatient at The Priory, and she told the court that Eleanor “looked tired”.
Dr O’Malley told the court: “She told me she’d not had any alcohol but had initially had a lot of craving, she did tell me there had been some ongoing issues with friends and that some people were making nasty comments about her on social media.”
Eleanor’s mood stabilisers were once again increased as Dr O’Malley said that her moods were still “up and down”, but she told the court that she had felt it was the right time to discharge Eleanor from inpatient care.
“It was only a discharge from inpatient so she would have still been having aftercare and ongoing treatment, but felt it was right for her to move to outpatient care”, Dr O’Malley said.
Sadly, less than a month later, on February 17 2020, Eleanor took her own life.
Dr O’Malley said that it “was a shock” to hear about Eleanor’s death, as she did not believe that the 19-year-old was a suicide risk, but Eleanor’s family told the court that they felt they had not been given adequate warning that she was still in a “fragile” state.
Her mother Elaine told the court that she felt she had been “lulled into a false sense of security” as she believed that Eleanor was much better, but she was in fact still struggling.
She said: “My main concern was we would have liked to have been aware of how fragile she was when she left The Priory. We’d become a bit complacent really as we thought she’d turned a corner, but if I was aware of how fragile she was that month we wouldn’t have been so complacent.”
But Dr O’Malley defended the decision to discharge Eleanor from inpatient care and told the court: “If Ellie had been thought to be a suicide risk she would not have been discharged.”
In the final moments of Eleanor’s inquest, the court heard that prior to her previous suicide attempts, she wrote notes which expressed her desire to die – at the time of her death, no such note was written.
For this reason, assistant coroner Tanyka Rawden recorded a verdict of misadventure and told the court that she believed Eleanor did not mean to die.
She said: “I’m going to find misadventure, which is an act with unintended consequences, so whilst I think she did take her own life I don’t think she meant to.
“It’s likely that this act that she did was an expression of her distress rather than an attempt to take her own life, I think it was something that was impulsive – we may never know what triggered it. I don’t think that was her ultimate aim. I think she was distressed and trying to express that distress through an impulsive act.
“Ellie was a very poorly young lady with a personality disorder which made her act impulsively.”
Paying tribute to her daughter, Elaine Lomax told the court that Eleanor “gelled the family together” and was desperately missed by her parents and siblings.
She said: “She was a beautiful little girl who, when she came into our life, she just gelled the family together she was smiley as a baby – she used to bounce about, she was like a tigger, she didn’t walk she bounced.
“We all adored her, she was our little baby.”