Inquest into the death of Maia Schroder-Lewis, aged 21

Cardiff University medical student Maia Schroder-Lewis died after her family reached out for help to community mental health services, GP service and ambulance service in her home city of Bristol. Maia took her own life aged 21 on 1 September 2022 during the summer vacation between her second and third years when she was living back home in Bristol.

The three-day inquest into her death concluded on Wednesday 6 March 2024. Area Coroner for Avon, Dr Peter Harrowing, concluded that Maia died by suicide. He recorded that Maia had suffered with a deterioration in her mental health in recent months, and as a result had had contact with the mental health services.

Maia’s family have expressed disappointment and frustration that it was an uncritical conclusion in relation to the treatment she received from Avon and Wiltshire Mental Health Partnership (AWP), South Western Ambulance Service NHS Foundation Trust (SWASFT) and Montpelier Health Centre.

Other families have raised concerns at their loved ones’ inquests about the mental healthcare provided by AWP in Bristol. Families have raised concerns that the coroner has not recognised concerns raised by the family. In the inquest of Jess Drury the family raised similar concerns following Dr Harrowing’s conclusions.

Maia’s inquest heard that she had been denied access to AWP Crisis Team mental health support through a Bristol helpline, because as a student, she was registered to a GP in Cardiff. Paramedics who were called to her house by her mother Anna Schroder on the morning of 31 August 2022 did not complete a mental health assessment on Maia or refer her to the mental health desk, but decided to refer her to a GP.

They were unable to get through to Maia’s Bristol family GP service at Montpelier Health Centre, despite calling 13 times even by use of a by pass line for professionals. When Maia’s mother finally contacted the GP he carried out the assessment by phone and made no referral.

Urgent calls to the AWP Crisis Team only resulted in telephone consultations, with a home visit made the day after Maia died.

Anna Schroder’s unchallenged written evidence to the court was that Maia had struggled when she started university in September 2020 and her experiences were deeply impacted by the pandemic. She was prescribed low dose anti-depressants during her first year, and moved back home to Bristol at Easter of her second year in 2022, intending to go back to Cardiff for the start of her third year in September 2022. In early July, she was prescribed Sertraline by her GP in Cardiff for low mood and anxiety, but her mood remained low throughout August.

On Tuesday 30 August, Anna called Cardiff Mindline, who advised her to call Bristol Mindline. A call handler spoke with Maia, but when it became clear that Maia was registered to a GP in Cardiff, told her she would have to re-register with her family GP at Montpelier Health Centre before she could access the helpline. It has been accepted by AWP that this call should have been transferred to a practitioner within the triage team.

Anna tried to re-register Maia with Montpelier but found it impossible to do so without attending in person with ID.

At 1.30am, 31 August, Anna took Maia to Bristol Royal Infirmary A&E, but eventually went home without seeing a doctor. The following morning Maia’s mood was so low that her parents called 999. The paramedics tried to call Montpelier Health Centre, but after 13 failed attempts, Anna walked with Maia to the practice where she re-registered as a patient. They returned home to await a call from the GP, which Anna asked the surgery to include her in.

Later that afternoon, Maia mentioned that the surgery had called briefly and sent links to a crisis line. No referrals were made into AWP by Maia’s GP. She was instead prescribed with anti-depressant medication and scheduled for a four-week follow up appointment.

Maia was still agitated and low, and after her mother found her attempting to self-harm she called the AWP Response Team. They triaged Maia as an emergency requiring a face to face assessment within four-hours, but this was not communicated to Maia or her family. The crisis line called back and following a telephone screening with Maia downgraded the referral without a recorded risk assessment. An appointment was made to see Maia at 3pm the following day.

That evening, Maia was again found by her mother attempting to self-harm and the Crisis Team were contacted, but again, they did not change their plan or consider Maia’s mother’s request for an emergency Mental Health Act assessment in hospital.

The following day, 1 September, the AWP crisis team did not attend in person, but instead made contact by telephone at 3pm. Maia was out of the house but the Crisis Team did not suggest that emergency services were contacted, as Maia was expected back. When Maia returned home she was upset that the Crisis Team had not attended in person and expressed concerns that they were ineffective and left the house again. When the Crisis Team called back, they were again unconcerned that Maia was out alone. They did not pursue further contact that evening or suggest that her risk level warranted emergency service involvement. Again, no risk information was shared about Maia’s earlier risk screening or triaged emergency referral status. The Crisis Team instead explained to Maia’s mother that there had been no reason to doubt Maia’s capacity, and attempting over-assertive engagement to try to conduct an assessment may not be appropriate. Tragically, Maia was found unresponsive later that evening.

Maia’s family are concerned that the Crisis Team assessment of Maia’s capacity and risks to self were inadequate and information sharing was flawed. They were advised by the Crisis Team that Maia had the capacity to refuse treatment if she wished. By this time, Maia had agreed to see a private counsellor and had also reached out to her university support services that day to discuss a break from her studies. The Crisis Team finally visited in person on 2 September to carry out their urgent assessment, but this was too late.

AWP NHS Trust carried out an internal review of the care provided to Maia which found no problems in service delivery. Due to the inadequacy of that investigation, AWP then commissioned a Serious Incident Review in June 2023. This identified the need for five safety recommendations that were shared with the family in February 2024. AWP acknowledged the need for Trust-wide training provision in risk assessment, formulation and risk management. In addition, Trust-wide training in risk-based information sharing and safeguarding protocols was needed.

Due to overriding concerns with the quality of the internal investigations to date, the Integrated Care Board (ICB) has agreed that there should be an independent review of the care provided by AWP. This independent review will also consider the response of SWASFT and Montpelier Health Centre to Maia’s mental health crisis.

Following the conclusion of the inquest into Maia’s death, Anna Schroder said:

“Our grief at the loss of Maia is profound and devastating. She was deeply loved and we will miss her forever. Maia was an amazing daughter, who touched so many with her compassion, fierce intelligence, energy and creative spirit. It has been traumatic to hear services identify extensive safety learnings and flaws in their risk assessment and information sharing processes, representing missed opportunities to help Maia in her mental health crisis. We are frustrated at the coroner’s uncritical findings, but welcome the forthcoming independent review into Maia’s care by the ICB.”

The family were also disappointed that was that they were not awarded legal aid funding to cover representation at the hearing when all other Interested Persons were legally represented funded by the public purse. The family were kindly assisted by Tim Baldwin on a pro bono basis.

Anna Schroder is represented by Leigh Day partner Leanne Devine, who said:

“This is a tragic case where Maia’s family knew that she needed help and reached out to numerous professionals to get the help she needed. Unfortunately, they did not get urgent assistance and as a result Maia took her own life. Maia’s family have been tenacious with their investigation surrounding the circumstances of Maia’s death. The initial findings from AWP were inadequate and Maia’s family had to push for a full serious incident investigation. Due to ongoing concerns about the adequacy of that investigation, it has now been agreed by the Integrated Care Board that a separate investigation independent to AWP is needed. We hope the evidence heard in the Inquest will assist the further investigations into Maia’s death.

“With regard to the coroner’s conclusion, the family are disappointed that the coroner has returned a non-critical conclusion as he has done in other cases involving AWP. We urge the ICB to ensure that there is an independent investigation carried out to prevent ongoing failures with the mental health care in the Bristol area.”

Maia’s family are supported by INQUEST who have highlighted numerous cases where failures have been identified in the care provided by AWP but the same coroner has returned uncritical conclusions.

It is noted that the coroner is due to return conclusions in relation to the death of Evangeline Wilson of Bristol who took her own life aged 24 in July 2022. Like Maia, there are concerns around the involvement of the Avon and Wiltshire Mental Health Partnership NHS Trust in Evangeline’s care at the time that she took her own life.

The above content is reproduced from a Leigh Day press release.