An inquest heard that a young lady with a history of mental health issues died after being hit by a car while sitting in the middle of the road.
Antonia St Louis, 27, sustained “unsurvivable injuries” in the early morning hours of November 28, 2020, in Ashton-under-Lyne, Greater Manchester.
The South Manchester Coroner’s Court inquest heard that Miss St. Louis and a companion were walking down Manchester Road near Snipe Retail Park before entering the roadway.
They stopped in the centre of the three lanes, and CCTV video revealed that Miss St. Louis, a beautician, was seated on the ground.
At around 3:40 a.m., a Volkswagen Golf driven by Andrew Copeland struck her.
Mr. Copeland, who remained on the unlit road to help authorities, was not charged.
Miss St. Louis died at the scene, according to the inquiry.
Dr. Charles Wilson, a pathologist, detected alcohol and cocaine in the system of Miss St. Louis.
PC Paul Terry, a forensic accident reconstruction officer, said in court that Mr. Copeland was travelling at about 40 mph at the time of the incident and had little time to respond owing to the darkness.
Dr. Wilson said that the fractures and internal problems caused Miss St. Louis to pass away “quickly.”
Her medical cause of death was listed as “chest injuries.”
In 2020, the court heard testimony from a variety of mental health doctors on Miss St. Louis’ mental health.
Coroner Adrian Farrow and Miss St. Louis’ family voiced concerns over several elements of her treatment, particularly her release at the end of September from a mental health facility to a home-based team.
Due to the delayed transfer of treatment to the Tameside Community Mental Health Team, her eventual release from this arrangement was also investigated.
A delay in assigning a care coordinator to maintain touch with Miss St. Louis has sparked concerns.
Mr. Farrow said that he thought a referral to a drug and alcohol service should have been made, which was referenced in clinical records but never carried out.
Miss St. Louis was institutionalised in September 2020, the inquiry heard.
As her mental health improved, she received this treatment for over a week.
On September 28, she was released from the Trafford General Hospital’s Moorside Unit’s Medlock Ward to a home-based therapy team.
The ward manager of the Medlock Ward, Sara Dalglish, said that Miss St. Louis’ mental health improved throughout her stay on the ward, and she became more aware of the negative effects of alcohol and drug use on her mental health.
Miss St. Louis met with home-based teams in early October and posed a minimal danger to herself and others; nevertheless, she was released on October 20 after making threats to staff and skipping two weeks of appointments.
She was subsequently seen by Laura Kamal of the community mental health team in north-east Manchester, who informed her that she had “no immediate concerns.”
Since her release from the home-based team, Ms. Kamal’s transfer of care to Tameside Community Mental Health Team has been delayed, causing her anxiety.
Mark Hynes from the Greater Manchester Mental Health NHS Foundation Trust said that a review of major incidents was conducted.
He acknowledged that Miss St. Louis’ move should have occurred sooner.
Mr Hynes said: ‘We would have expected a care coordinator to have been put in place at that time [after discharge].’
Mr. Farrow believed that a referral to drug and alcohol services was essential, but Mr. Hynes said that there was no indication that a reference had been made.
He agreed with the coroner that a coordinator to manage Miss St. Louis’ care and transfer to the Tameside team would have been advantageous, but it “just didn’t happen.”
Mental health service manager Glyn Hulme, who drafted an action plan in response to the case, stated that changes had been made to address the ‘gap’ in Miss St. Louis’ care, including conducting more in-depth risk assessments and ensuring more administrative staff is available to reduce transfer delays.
The inquiry heard that a central “hub” has been established as a point of contact for patients before they are given a coordinator.
Mr. Farrow found that Miss St. Louis died in a car accident after consuming alcohol and controlled substances.
He said that she had suffered from anxiety at a young age, which she ‘regulated’ with weed and excessive alcohol use.
Mr. Farrow said that a referral to a drug and alcohol programme was “considered” in September 2020, but there was “insufficient” evidence that it was implemented.
The coroner said that Miss St. Louis had contemplated self-harm in the past, but that there was no evidence to indicate that she was in that state of mind at the time of her death, nor was it probable that she sat in the road with the intention of putting herself in risk.
He criticised the mental health service’s shortage of personnel, particularly care coordinators, as “unsatisfactory.”
Mr Farrow said: ‘That person [a care coordinator] may have been able to address her complex needs around alcohol and drugs and may have been a source of support for her.
‘But I can’t say a care coordinator would have stopped her from drinking as she did on November 28.’
Miss St Louis’ aunt, Tanya Roxbrough, said her niece was a ‘lovely girl’ who ‘loved her family’ and was ‘quite a character’.
She stated that Miss St. Louis had battled throughout the first Covid lockdown, which had negative repercussions for her mental health.