A bereaved mother has said she repeatedly raised concerns about the mental health of her daughter who died after jumping in front of a train with her three-year-old.
Yvette Redmond sought help for Leighane Melsadie Redmond by taking her to A&E, calling 111 and going to her GP. Leighane, who was suffering from psychosis, and her daughter, Melsadie Adella-Rae Parris, died at Taplow station in Buckinghamshire on 18 February 2019.
At an inquest into their deaths in November, the assistant coroner Ian Wade KC concluded Leighane, 27, was likely to have been “legally insane” at the time. He ordered Buckinghamshire council children’s services to set out how it would prevent future deaths.
Redmond, who lives in Beaconsfield, has condemned the mental health system as “beyond bad”. The 53-year-old, a mental health wellbeing worker, said: “If you don’t know the system, you’ve got no chance of getting your loved one sufficient help.”
Sitting in her living room surrounded by photographs of Leighane and Melsadie, who was known to her family as Sadie, she said: “I feel really let down. They didn’t need to die. I understand that Leighane’s an adult but we could have saved Sadie. That’s what haunts me. There was a three-year-old girl who needed protecting.”
Redmond said Leighane, who was separated from Melsadie’s father, suffered a mental health crisis on 23 December 2018. She recalled: “I got a call from Leighane. I didn’t fully understand what she was saying. It was incoherent. She said a lot of words, but the words didn’t go together: ‘They’re going to kill me. You need to come now.’”
Redmond and her niece rushed over to Leighane’s flat in Taplow. Fighting back tears, Redmond said: “Sadie’s bed had gone, Leighane had smashed it up looking for cameras. She’d ripped the heads off Sadie’s teddy bears looking for cameras. All the electrics were off in the flat. She had taken the television and wrapped it in bubble wrap and put it under the bed.”
Leighane described Melsadie as “evil”, Redmond said, adding: “I knew then she was very unwell. I didn’t know what to do. That’s the thing I want to get out – what do you do when you’re faced with that?”
Redmond took Leighane to A&E before calling 111, which prompted police to do a welfare check on Melsadie. A mental health crisis team also visited but Leighane did not answer the door. Social workers placed Melsadie into the care of her father while Leighane waited for a mental health assessment on 29 December.
On Christmas Eve, Redmond visited Leighane’s GP, who told her it sounded like psychosis. But she said there was nothing she could do unless Leighane sought help herself. “By this time I was frantic, I was crying. I was inconsolable. I was scared for Leighane, I was scared for Sadie,” Redmond said.
When Oxford Health NHS trust carried out a mental health assessment five days later, they found no evidence of psychosis and Leighane was diagnosed with mild to moderate depression.
Melsadie was returned to her mother’s care but Redmond said nobody contacted her. “Nobody went to Leighane’s flat. Nobody came to see Sadie. Nobody came to assess anything. It was all done on the phone,” she said.
Redmond believes social workers should have conducted a home visit. “Had they gone at any point between 23 December and their deaths, you would have seen quite clearly that Leighane had psychosis just from the state of her flat,” she said.
In his prevention of future deaths report, the coroner said the mental health assessment that Leighane was not psychotic had been appropriate at the time. But he said social workers were told by two people in January 2019 that Leighane had described Melsadie as evil.
He said: “The team did not conduct a renewed visit to the home, nor seek up-to-date information from the family, nor liaise with the mental health team. It is likely that if they had done so they would have discovered more detail of the extent of [Leighane’s] mental illness, which was indicative of paranoia with depression, linked to concealment of ongoing episodic psychosis.
“It is possible that a further mental health assessment would have been sought, and arrangements made to remove Melsadie from the custody of the carer.”
He said social workers instead relied on evidence gathered during an “irrelevant” investigation that pre-dated Leighane’s mental health problems.
He concluded that Leighane had died of suicide, but delivered a narrative verdict to the inquest of Melsadie, who he said was well cared for and loved by all her relatives. He said Leighane had been discharged from the mental health team on 29 December on reasonable grounds. But he said children’s social services had “missed” an opportunity to inspect Leighane’s home and to seek evidence from her family of her developing mental illness when additional concerns came to light.
“It cannot be concluded that such an opportunity, if taken, would have made any difference to the outcome,” he added.
Merry Varney, a partner at law firm Leigh Day, said: “Not only was Yvette not listened to before their deaths, but it has taken years for some of the missed opportunities by public bodies to be exposed.
“As the coroner recognised by issuing a prevention of future deaths report to Buckinghamshire children’s services, lives remain at risk and it is shameful it has taken this long for this to be recognised and acted upon.”
Anita Cranmer, Buckinghamshire council’s cabinet member for education and children’s services, said: “Buckinghamshire Safeguarding Children Partnership – which is independent of the council – carried out a review of this terrible incident to examine thoroughly the decisions made prior to the deaths. This review ultimately concluded that no one could have predicted what happened and did not attribute any blame or highlight any failings.”
She said the coroner had concluded that the council investigated appropriately on 23 December, checking Melsadie was safely cared for by her father and ensuring a mental health assessment was undertaken.
She said social workers attempted a home visit on 7 January 2019 and that the council would be “reviewing processes and procedures to ensure the coroner’s remarks and recommendations are reflected in our practices”.
In the UK and Ireland, Samaritans can be contacted on 116 123, or email jo@samaritans.org or jo@samaritans.ie. In the US, the National Suicide Prevention Lifeline is 1-800-273-8255. In Australia, the crisis support service Lifeline is 13 11 14. Other international helplines can be found at befrienders.org.
