Hucknall woman took her own life despite warning she would kill herself if she was sent home
A Hucknall woman tragically took her own life shortly after she was discharged from hospital despite warning she would kill herself if she had to return home, an inquest heard.
Rachel Elizabeth Stolarska was found at her home on February 10 2025, at the age of 58, said Neema Sharma, assistant coroner for Nottinghamshire.
The inquest heard Rachel had made two previous suicide attempts and her mother had emailed the hospital voicing fears she would try again.
She had been diagnosed with a depressive disorder and was alcohol-dependent but suddenly stopped drinking and smoking following a cancer diagnosis two years previously.
Her family wondered whether going cold turkey affected her mental health as she cut off all contact with them after she went into Sherwood Oaks hospital in July 2024, the inquest heard.
Rachel was due to move into a placement but was detained under the mental health act on October 28.
A move to place her at Beacon Lodge fell through after staff at the facility said they couldn’t manage her risk as she had previously taken an overdose there.
Poppie Ross, her social worker between August and December 2024, raised concerns that Rachel had not yet been allocated a community psychiatric nurse (CPN) after she was sent home on January 7 last year.
Helen Broadhead, a community care officer for Nottinghamshire County Council adult social care, said she tried to visit Rachel at home eight times without success and all her phone numbers were out of order.
A letter offering a visit on January 31 was ignored and there was no secure place to leave her medication, she added.
Rebecca Keating, clinical director for adult mental health care at Nottinghamshire Healthcare NHS Foundation Trust, reviewed an investigation into Rachel's case.
She said she has since improved communication lines and set up additional meetings to monitor safety, staffing levels and ensure the safe discharge of in-patients back into the community.
Jenna Davies, interim matron for county south local mental health teams, said her role was created after Rachel's death to monitor standards of care.
"We had a very inconsistent and almost ad hoc way of overseeing in-patients who didn't have an allocated CPN," she said.
An in-reach nurse will attend discharge planning meetings and work with other agencies like social care or Framework and then report back shortly after discharge.
“I am not hiding from the fact we are not happy with our waiting lists,” she said. “The information flow is a lot tidier now. There are fewer places where information can get loose.”
She said the point of her role is to improve nursing and clinical skills, act as a role-model and encourage curiosity among nurses.
Recording a narrative verdict at a separate hearing on Friday, July 31, Ms Sharma said that “opportunities had been lost” and that she considered Rachel’s discharge “unsafe” as no social worker had been assigned to her at the point of discharge, and her concerns about returning home had not been given thorough enough exploration.
She criticised poor communication between various agencies regarding Rachel’s care, and spoke of her disappointment that not enough professional curiosity was evident by professionals involved in various areas of her care.