By Pamela McGowan

Last updated at 12:45, Friday, 30 October 2009

A widow who doused herself in petrol and set fire to it was still grieving after losing her husband to terminal cancer, an inquest heard.

Grace Armstrong

But despite the coroner ruling she deliberately killed herself, her sons still believe it was a cry for help and an attempt to get herself readmitted into psychiatric care.

Grace Armstrong, 73, of Newtown, Irthington, made the suicide attempt on August 7 last year – just six days after being discharged from the Carleton Clinic. The grandmother died from her injuries three days later at Newcastle’s Royal Victoria Infirmary.

Her death followed over a month of treatment for depression and suicidal thoughts. Her two sons, Neil and Maurice Armstrong, told Tuesday’s inquest they felt their mother had been let down by the system and called on NHS bosses to review procedures.

The full-day inquest heard how Mrs Armstrong, a retired carer, had nursed her husband Harry through his battle with cancer for more than two years.

But following his death in March 2008 she was left with a void in her life and grew depressed. She had a history of mental illness and several suicide attempts, dating back decades.

At the end of June last year she was referred to the Cumbria Partnership NHS Foundation Trust, which provides mental health care after speaking about her plans to set herself on fire. Mrs Armstrong was admitted to the Carleton Clinic’s Oakwood inpatient unit under her own free will. She was never sectioned.

Over the next month or so she was observed by specialists, who saw her moods varied dramatically. They began a phased return home with supervision.

Most of the time she would cope well but on one occasion, on an overnight visit home, she drank a small quantity of bleach, resulting in her being readmitted. Her younger son Maurice, 46, who lived locally, had planned to take her with him on holiday but it was deemed safer for her to remain in the care of the Cumbria Partnership. But he later returned home on August 3 to find his mother had been discharged.

The inquest heard this decision was based on Mrs Armstrong’s good progress and her own wishes. She was receiving daily visits from support workers, who said she was coping well.

But on the morning of August 7 she rang Maurice at about 7am saying she didn’t feel well. He suggested she ring the clinic so she spoke to a nurse about her feelings, though denied any thoughts of self-harm.

The nurse then contacted the local crisis team, who had already arranged to check on her that afternoon. However before this visit happened Mrs Armstrong took a cup of lawnmower petrol from the garage and a lighter into a nearby field and set fire to herself.

She suffered severe burns covering 50 per cent of her body. She then walked back to the village and asked a neighbour for help.

She was airlifted to Newcastle hospital, but her family were told she would not survive. She died in intensive care on August 10.

Her sons told the inquest they felt her actions – like the bleach incident – were a cry for help. They did not think she realised the damage such a small amount of petrol would do, nor that she’d have done it without leaving a note.

“I’m 100 per cent certain my mum didn’t want to kill herself. She only took one cup full of petrol when I’d previously filled the tin. If she’d wanted to kill herself she’d surely have taken the whole tin,” said Maurice.

They also expressed concerns that their mother was discharged so soon after the bleach incident, while they were both out of the country, and why her phone call to the clinic on the morning of her death was not followed up immediately.

In addition, they felt that a form given to her on release – which detailed her suicidal thoughts and talk of setting herself on fire – had given her the idea to do what she did, in a bid to get herself readmitted.

However coroner David Roberts also heard evidence of her constant talk of wanting to end things, including threats to set herself on fire. He ruled she had deliberately killed herself while grieving for her husband, and ruled mental health staff had acted correctly.

After the inquest her sons said they were disappointed with the verdict as they felt there was too much doubt over her mindset to say it was definitely suicide. They also said that the legitimate concerns they raised about their mother’s care “seemed to fall on deaf ears”.

Neil stressed they were not criticising staff, but felt the procedures they have to follow need to be reviewed. “I think we have been let down by a system which I believe pushes them to make decisions which are not in the best interests of the patient.”

Andy Roach, the Cumbria Partnership’s director, said they recognised the coroner’s comments that the correct procedures were followed and aftercare provided. But he added: “We are always open and willing to meet with the family and discuss any additional concerns they may have.

“We are working to reduce the numbers of deaths from suicide and always ensure we reflect on improvements we can make to our services.”

First published at 11:35, Thursday, 29 October 2009
Published by http://www.newsandstar.co.uk