A woman from South London who loved “tea, cigarettes, and bingo” died suddenly at her home after stopping her anti-epilepsy medication despite being under the supervision of care staff. Tanya Veiga, 48, was found “face down” in her one bedroom supported accommodation flat on Samuel Close, in Bermondsey, by staff at Bridge Support around 7.30am on July 29, 2020. Sadly paramedics who rushed to the scene were not able to save her.
In a hearing at Southwark’s Inner South London Coroner’s Court, Tanya’s mother Jenny Williams – who lives on the Isle of Wight and has had cancer – wept and broke down as she gave evidence about the lead up to her daughter’s early death. Describing her daughter, she said: “Her main loves in life were tea, cigarettes, and bingo. She would go on the bus to Woolwich, go get a coffee, sit outside on the street, have her cigarettes and go out to bingo. That was all she did at the end, the past few years.
“I used to ring up Margaret [Tanya’s care co-ordinator] and be told ‘She’s fine, don’t worry’. Then I would say next time can I speak to her and they would say, ‘No, she does not want to speak to you’. I was very upset I did not get much contact with where she was staying, I used to ring but never got much contact or information. Maybe because she got to the age where I had no input anymore.”
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(Image: Manchester Evening News)
“I felt that the last place she was in it was very difficult to have any contact with anyone there, whereas other places were really accommodating and would bring her to see me,” Jenny added. “When I did go to see her I had to put a complaint in because her place was absolutely disgusting. I had to take her to a public toilet it was that bad. I put in a complaint and it says on the record that someone would have to go in and help clean.
“I last saw her a year, or year and a half, before she died. I was unwell but I just did not have the contact. The other one I would have weekly contact, they would say Tanya needs her hair cut and I would send money.
“This place I would take her out and buy her new bedding or send it through the post to her. She would never do any washing, just throw them away. I would go there and there would be no bedding and no food in the cupboard. Even in the notes I am not listed as next of kin. I did not know she had died until 6.30 that evening, nobody rang me. I just felt she did not get the care, I did not get the care.”
Coroner Sarah Valentine grilled witnesses from the various agencies in charge of Tanya’s care, first asking her care co-ordinator Margaret Owoye from Oxleas NHS Foundation Trust to give evidence. Ms Owoye explained how Tanya’s mental health symptoms were “quite intense” which meant she needed a lot of support. But, they had looked to reduce this as she became more stable on her medication.
After reducing her care to medium support – which was limited to just morning and evening visits – she told the court how medication non-compliance had forced her to bolt on a medication package to make sure she was taking antipsychotic clozapine and two anti-epilepsy drugs.
‘We could not force her to take anything’
Despite the package – which involved visits from Eleanor Care – she recalled issues with Tanya’s medication compliance and detailed how as an “early riser” she would often be absent at the time she was supposed to take the drugs. She said: “It’s really difficult because you’re late but you could never tell when she was going out early. Sometimes Tanya would be in and she would not answer her doorbell. They would try the doorbell for a long time, she would not pick up her phone it was at the bottom of her bag.”
Coroner Valentine responded, asking questions like, “How many no shows and failures to take medicine prompts you to do anything?” and “What do we do to change the status quo and make sure she is compliant?” To this Ms Owoye said: “We could not force her to take anything, we could only encourage her, that was the only thing we could do.”
Bridge Supported Accommodation manager Paul Simkins was also called to explain their role in Tanya’s care. He stressed “we are not a care home” and she was living independently, but that staff performed welfare checks everyday. These were done after 9am when staff were at work, though they would prioritise Tanya as she was known to leave early.
Explaining their role in her medication, he said: “When she was in we would just prompt her to take her medication. All we would do is open the cabinet because we do not handle medication either.” Coroner Valentine remarked there seemed to be “a fine line between administering and not administering”.
Caroline Green from Eleanor Care – the company charged with overseeing Tanya’s medication and cleaning – was asked to give oral evidence after the coroner found the written evidence to be “one of the poorest statements I have seen”. She opened by admitting the journal system with some of the relevant notes was “no longer being used”.
Ms Green continued: “If there was any issues with medication where it had not been taken, the carer would inform us or the team at the house.” Discussing what it takes to escalate things following non-compliance, she said: “We are just there to assist with medication or prompt medication.”
Tanya’s medical cause of death was confirmed as sudden unexplained death by epilepsy following a post-mortem, however further toxicology reports noted the absence of any anti-epilepsy medicine in her system indicating she had stopped taking it. The coroner noted “non-compliance with medication is a recognised risk factor with SUDEP”.
Tanya’s death sparked a serious incident investigation by Oxleas NHS Foundation Trust which identified several key learning points. Investigator Aydin Misiri told the court there were “a number of things that did not happen”, including increased contact and re-triggering a risk assessment.
He admitted when she was risk rated at red “she should have been seen three times per week and she was not, so it fell below the expected standard”. He added the panel report found “the care on offer did not meet the standard” and “we did not find any impact that Covid had on Tanya’s treatment”.
When asked by the coroner if Oxleas audits care co-ordinators to ensure a consistent standard, Mr Misiri said: “I can’t answer for certain.”
Coroner Valentine responded: “I think what’s key is to review active management and not retrospective action after someone has died.”
In her closing remarks, she added: “The findings of this report say there could have been better contact and frequency of communication with the care co-ordinator. There were calls but it was really difficult to understand what follow up there was agreed with multi-agency groups.”
Making a narrative conclusion, the coroner detailed how Tanya had a history of mental health issues, but at the time had not been sectioned. Due to her non-compliance with medication she was subject to a medication management plan which involved taking medicine out of a safe she could not access.
Two days prior to her death she went to a review appointment where a referral was made, but this was outstanding on her death. She again noted non-compliance with medication was a known risk factor for sudden unexpected death in epilepsy.
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