Published: 00:01, 24 November 2016
A 36-year-old with bi-polar disorder died the day after she’d agreed to a package of care with her social worker, an inquest heard.
Karoline Valleton de Boissiere had suffered with mental health issues including bipolar disorder since she was 12.
She was found by her mother Alison Stevenson in her bedroom in Church Path, Deal, on Sunday, May 1.
Speaking at Canterbury Magistrates’ Court last Wednesday coroner Christopher Morris concluded her death was an accident.
He gave her cause of death as venlafaxine overdose and alcohol intoxication. Venlafaxine, a prescribed drug, is used to treat major depression.
Her has prompted the South Kent Coast mental health team to cut its case loads.
At an inquest into the 36-year-old’s death Karoline’s family raised concerns about the continuity of care on offer to mental health patients.
Speaking at the coroners court at Canterbury Crown Court last Wednesday, her mother Alison Stevenson said: “There always seemed to be a tremendous gap between visits and there was nobody available immediately when Karoline was in such a bad way.
“There was always this big gap. Why did no one come running?”
The 68 year-old, of Church Path, Deal, found her daughter dead in her bedroom on Sunday, May 1,
Maria Gallagher, service manager for the South Kent Coast mental health team, said she wanted to help Karoline’s family after they raised these issues.
The social worker was invited to give evidence at the inquest although she’d had no personal involvement with Karoline.
However, she took the lead in Karoline’s learning review – something which is carried out after the death of any patient – where issues over the level of contact were raised.
She told the court: “Through our investigations it became clear that it was something of a juggling act, because when Karoline was well she got on with her life but she did engage with us when she was less well.
“One of the issues that came up was how proactive the care co-ordinator should be when a person is well and less well.”
This has led the team to consider their individual case loads.
Ms Gallagher said: “There has been lots of recruitment. In August we had eight vacancies and it has been quite difficult but we’ve had a very positive recruitment of five nurses, one social worker and one occupational therapist.
“There is some transformation work going on at directive levels to reduce case loads quite dramatically. We’re looking to reduce case loads from 70 to 35.
“I hope we’ll be seeing a difference in three months and more thereafter.”
Mrs Stevenson has been invited to meet with the team, at a date to be arranged, to continue discussions of her concerns.
She has also written to MP Charlie Elphicke about improvements to the ambulance service, suggesting they have access to patients’ notes so they’re more aware.
Karoline had recently moved back in with her mother after her drinking habits had worsened. She had left a bath running in her boyfriend Harry Evans’s home which prompted his landlord to evict her.
On Friday, April 28, Karoline had met up with Mr Evans and another friend Christopher Rowbotham, who she had worked with at St Anselm’s Nursing Home in Walmer.
After lunch with Mr Evans at the Sir Norman Wisdom in Deal – where she drank a pint of lager – she met up with Mr Rowbotham.
He told the court Karoline had a bag with cans of lager with her. They went to Tesco in Whitfield and then to the Fleur de Lis in Sandwich where Karoline had another pint but did not finish it.
Feeling that she was disorientated, Mr Rowbotham returned her home to her mother safely.
Mrs Stevenson said her daughter was so intoxicated she could not stand. She contacted Dover Mental Health Team for help.
The next day, Saturday, April 29, Karoline was visited by social worker Jonathan Tucker.
He said: “We did have a good discussion and made some decisions about what she was going to do and it gave me some hope.
“We made a plan for her to see Turning Point and I gave her the phone and she made an appointment.
“She agreed to see one of our support workers which I thought was really positive as she’d never agreed to that before.
“We had a package of care in place. I felt pleased that she agreed to that.”
Mr Tucker told the court: “She had said she was sad. It had been to the anniversary of a friend’s death.
“I did ask her directly if she was having thoughts to harm herself and she said no.
“She did say she was worrying about where she was living, about her children and she wanted to do something about it.”
The next day, Karoline was found in her bedroom surrounded by empty packets of prescribed drugs and alcoholic drinks.
Having read her daughter’s diary and found two tickets to a gig in London for the end of May, Mrs Stevenson said she did not believe Karoline had taken her own life.
Police ruled out any suspicious circumstances.
Coroner Christopher Morris said: “Karoline was much loved but a troubled person.
“I’ve heard that she experienced mental health difficulties since her childhood but was diagnosed with bipolar.
“In my opinion she was being affected by the death of a close friend and had alcohol issues.
“Karoline had engaged with mental heath services with different levels of intensity.
“By April, she had moved in with her mother. On April 29, she tried to engage in a sustained way with mental health services and Turning Point.
“There is no meaningful evidence before this court that suggests Karoline intended to take her own life. My conclusion is that it was an accident.”
Karoline was born Caroline White and later changed her name by deed poll.
The former Astor College pupil was mother to nine-year-old twins, who live with their father.
She had worked as a carer at St Anselm’s Nursing Home in Walmer. She was described as a “very clever girl” and enjoyed painting and running.
She had taken part in Race for Life in aid of Cancer Research UK. Her latest aspiration was to become a reporter.
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