Inquest highlights failure of NHS trust to carry out mental health assessment on Wanstead woman

An east London NHS trust failed to assess a woman’s mental health in the months before she killed herself despite repeated referrals from her GP, a coroner has found.

Aleksandra Markowska, 41, ended her life on September 30, 2021 near her home in Wanstead, two and a half months after losing her unborn child.

Aleksandra’s GP surgery referred her to specialist mental health services repeatedly in the months before her death, but no full assessment was ever carried out.

Concluding the inquest on Tuesday, east London coroner Nadia Persaud found North East London NHS Foundation Trust (NELFT) had failed to “robustly screen” Ms Markowska’s mental state.

The coroner also found NELFT had failed to provide “joined-up working” between the different mental health teams Aleksandra came into contact with.

Reaching a narrative verdict on September 27, the coroner said: “She took her own life whilst suffering from pregnancy-related depression and anxiety.

“She had suffered severe symptoms for four months but, despite seeking support, she did not receive a review from a perinatal psychiatrist.

“She received contact from multiple teams, but did not receive a full mental health assessment.

“There was an absence of joined-up working and an absence of psychiatric attention.”

However, the coroner said she was not “clear” about whether Aleksandra’s death would have been avoided if a full assessment had been carried out.

In a statement read out at the start of the two-day inquest, her partner of 14 years, Ishaque Mir, said he felt “incredibly let down” by the health services.

He added: “Her condition should have been managed much better, her death was completely avoidable.

“She was 41-year-old active professional, she should not have been allowed to reach the point where suicide was her only option.

“During her illness she felt like a burden and was being passed around by the health services.”

Mr Mir wrote that after the loss of their child in July, his partner’s mental health had “declined severely”.

He added: “Even the day she went missing, I called the NHS for assistance, they told me to make an emergency appointment with the GP. I feel that all the services did not recognise the urgency at all.

“She did have ups and downs with her mood like everyone does and also had unreconciled issues with her father – this added to her bereavement and she wasn’t herself for several months.”

Aleksandra’s brother Maciej Markowski, who attended court with Mr Mir, said his sister grew up in Rypin, a small town in Poland, and moved to London when she was 19.

He said their father’s aggressive behaviour after drinking alcohol had a “lasting effect” on her, including anxiety about her health as an adult.

Despite this, she managed the stress of her job as a project manager at a bank, lived a healthy life and was “always up for endorphins”.

He added: “I would never have believed that she could hurt herself in any way.”

At the time of her death, Ms Markowska had been discharged by NELFT without a full mental health assessment or risk assessment ever being carried out.

Evidence from her GP surgery, The Shrubberies Medical Centre in South Woodford, was that she was first referred to NELFT’s perinatal team for the “urgent attention” of a senior psychiatrist in July.

Dr Vu and a colleague both chased up the referral to NELFT but did not hear back as they would have expected.

Mr Mir also contacted the perinatal team at least twice to raise his growing concerns about hi partner’s deteriorating state.

But the team told him it was “not an emergency mental health service” and suggested he contact 111, call NELFT’s mental health service at Mellmead House or go back to her GP.

On August 8, the specialist perinatal mental health team at NELFT, which was still in its pilot phase after starting in July, discharged her.

Psychological therapist Shireen Sultana, who first screened Aleksandra, said she was not considered a high risk because there was no history of mental health issues.

She added: “We were in really early days and it was my first meeting with her, so I was not really sure what would be a suitable course of action.

“She said that this wasn’t a pregnancy-related problem – in the call there was nothing concerning to me, she was very clear.

“If I became aware of that I would have explored it further with her and done a proper risk assessment.

“I have reflected on this tragic death, as a team we’ve been trying really hard to make this a better procedure through risk assessments, contacting the GP and action plans.

“We take sleep problems very seriously as a risk factor – and partners’ involvement, we try to contact them as well.“

A spokesperson for NELFT said: “We wish to offer our heartfelt condolences to Aleksandra’s family, friends and loved ones at this very difficult time.

“The trust will reflect on the coroner’s findings at the inquest to ensure that the quality of care at the trust continues to improve.”

NELFT provides community health and mental health services in Barking and Dagenham, Havering, Redbridge, Waltham Forest, Essex and Kent.

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Josh Mellor

Local Democracy Reporter