Mother of young woman Beth Langton says daughter ended her own life after feeling 'abandoned' by care system
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The care received by a 22-year-old woman who ended her life after buying a poisonous substance online has been criticised for a raft of "astonishing" "failings and misunderstandings" by her mother. Beth Langton, who had been diagnosed with a personality disorder and complex post-traumatic stress disorder, was found in her flat in Retford, Nottinghamshire, in February last year, an inquest was told.
Evidence considered by the coroner showed there had been a "significant reduction" in the support she was offered in the run-up to her death, leading to her mental state being "adversely affected". Shelley Macpherson, Beth's mum, told the BBC the inquest revealed "worse" failings than she had imagined.
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Hide AdHer daughter's mental health issues began when she was a teenager, and led to her being sectioned aged 17, receiving ongoing care. She eventually moved to a flat at Oakwell House - a residential home for women with mental health conditions - and received constant support from staff.
"She had 24/7 support from the staff and support from the community mental health team," Mrs Macpherson said. "But in 2022, the NHS trust [Nottinghamshire Healthcare NHS Foundation Trust] discharged her saying she had enough support in the community."
The family were unhappy with the changes to care and medication, she added, but as an adult, Beth had to give permission for her mother to intervene in her care. "That year, we had a difficult Christmas. From then onwards, until she died, she was not in a good place. She was disengaged with everything," Mrs Macpherson, 48, said.


In the lead-up to her daughter's death, she said Beth had arranged to meet her council-appointed social worker and had asked to have all her "observation hours" at Oakwell House removed - meaning staff were not required to have one-to-one time with her. "We were shocked that the social worker agreed to that without consulting anyone else," her mum said.
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Hide AdThe night before she died, Beth rang her mother, and seemed "more positive". "She asked me if I was upset with her and I said, 'no of course not, I love you'," Mrs Macpherson added. "Looking back, that kind of makes sense now."
Police called at her home the next day and broke the news of Beth's passing, she said. "Beth was very creative - she was really talented at writing poetry and she used it a lot to deal with her emotions. We've got a lot of her poems now," she went on. "As a child, she was a happy-go-lucky little girl. She loved to do things especially if it was something she could win at. She'd try anything."
An inquest at Nottingham Coroner's Court, which concluded last month, heard Beth sourced a poisonous substance online, which she had "deliberately ingested with the intention of bringing about her death". In addition, Coroner Laurinda Bower found decisions to reduce the support offered to Ms Langton "were often made in silo and on the basis of inaccurate information about the support Beth was receiving".
"The withdrawal of support led to feelings of abandonment and rejection linked to Beth's personality disorder," the coroner went on. “These feelings of abandonment and rejection were one of many issues that adversely affected her mental state in the lead-up to her suicide."
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Hide AdThe coroner later issued a prevention of future deaths report to various agencies, which highlighted the role the internet had played in her death, which she called "guidance". The report, which followed the inquest's conclusion on July 8, said: "That same guidance was still readily available on the internet at the time of her inquest, although I believe it might now have been removed.
"What system is in place to ensure that such websites are detected promptly and made unavailable to the public in a timely fashion?"
Leigh Day Solicitors, which represented Beth's family at the inquest, said she had been receiving input from Gillian Merrill, a clinical psychologist contracted by Oakwell House. The firm said Oakwell and Ms Merrill did not have a written contract or terms of reference for her role or the support she would give to Ms Langton, which had "created significant misunderstandings across the agencies involved in Beth's care", including over concerns about her discharge from NHS care in the spring of 2022.
"The coroner heard evidence the decision was taken in large part as a result of a mistaken understanding about Ms Merrill's role and the psychological services she provided to Beth," the firm said. "Beth is documented as having herself informed the mental health team at the time that she was not receiving the support they understood she would be, something which her care coordinator admitted at the inquest should have led to a reconsideration of her discharge."
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Hide AdMrs Macpherson said the evidence given to the inquest had been "astonishing". "It was extremely distressing," she said. "We thought we knew there were failings and missed opportunities but it was so much worse than what we imagined. All I ask is that things are improved so this doesn't happen again."


Creative Care, which runs Oakwell House, said Ms Merrill had been self-employed and provided a "drop-in service for staff and residents". She was "not intended to replace any prescribed care package", it added. "The decision as to the level of support received by service users in the form of a care package is determined by medical professionals and social services and not Creative Care," the firm said.
"We are aware of the coroner's concerns around a misunderstanding about services that led to a disjointed package of care, and steps have been taken to improve interagency communications."
Dr Susan Elcock, executive medical director and deputy chief executive of Nottinghamshire Healthcare NHS Foundation Trust, said: "We are working with our partner agencies to address the issues raised by the coroner and improve the experience of care for our current and future patients."
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Hide AdAnd Melanie Williams, executive director of adult social care and health at Nottinghamshire County Council, added: "Nottinghamshire County Council carries out regular reviews of its practices and the support it offers and will always make any improvements that may be required."
Merry Varney and Caleb Bawdon, solicitors at law firm Leigh Day, and Tayyiba Bajwa from Doughty Street Chambers represent Beth’s family. Caleb Bawdon, a solicitor in Leigh Day’s Human Rights team said: “The coroner’s conclusion comes as a result of the determination of Beth’s family to highlight the issues which led to her death.
“The coroner’s findings reflect what Beth’s family sadly already knew – that she was badly let down by services and professionals charged with her care. Despite the family’s repeated efforts to raise concerns while Beth was alive, multiple agencies and individuals failed to coordinate and put in place the support she needed.
“This meant that in early 2023 Beth found herself discharged from the local mental health team, receiving no psychological treatment or therapy, and no longer subject to any kind of one-to-one care by support workers. This significant reduction in support led to Beth feeling abandoned and rejected, and would not have happened had Beth and her family been listened to.”
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