Coroner: mental health services should have offered more help after mother with post-natal depression drowns

A coroner has found that Victoria Taylor, a 34-year-old mother from Malton, North Yorkshire, who drowned in the River Derwent after struggling with post-natal depression, should have received more help from mental health authorities. Ms Taylor disappeared from her home on the morning of Sept. 30 last year and was found three weeks later in the river after a search conducted amid heavy rainfall and high river levels. The inquest heard she had previously turned to alcohol to cope with childhood trauma and that her death followed a sequence of assessments that did not yield a coordinated action plan.

Area Coroner for North Yorkshire and York Catherine Cundy raised concerns about the lack of coordination between mental health services following Ms Taylor’s death and urged agencies to work together to prevent future tragedies. The coroner said that Ms Taylor entered the water intentionally, but she did not conclude she was intentionally attempting to end her life. In a tribute, Emma Worden described her sister as 'fiercely loyal' and said she had been failed by what she called systemic neglect by mental health services.

Ms Taylor, known as Vixx, had three separate assessments by crisis and acute health teams between May and August 2024. Each assessment concluded there was nothing further that those teams could do. The inquest examined whether NHS mental health services missed opportunities to intervene, given that she had previously expressed suicidal thoughts and that multiple agencies were already involved in her care. The records show that despite her expressions of distress, there was no follow-up action from secondary mental health services beyond the limited safety plans created after each assessment. The documents also indicate a lack of discussion about addressing the root causes of her distress, notably unresolved childhood trauma.

Following the second assessment, there was mention of a private psychotherapist as a potential route, but there was little explanation as to why this would be appropriate, and Ms Taylor reported that she had left a message with the private provider with no timely reply. A further assessment on August 20 placed her in the emergency department for a check-up after her fiancé found empty pill packets; she was described as tearful and low in mood, drinking three bottles of wine to cope with distress. Paramedics reported that she had taken pills with the intent to die, though she later told the responders it was an impulsive act and she felt silly about it.

These assessments occurred between mid-May and the end of August 2024. After Ms Taylor vanished at the end of September, her body was recovered from the River Derwent on October 22. The Derwent was in full flood at the time due to heavy rain. The coroner noted that while Ms Taylor told assessors her binge drinking and impulsive self-harm were linked to trauma, there was no record of a trauma-focused treatment pathway being offered through the Community Mental Health Team, nor any indication that such pathways had been proposed to or rejected by Ms Taylor.

The coroner sent the report to Tees, Esk and Wear Valley NHS Trust, Horizons Scarborough, Derwent Practice in Malton, the Department of Health and Social Care, and the Chief Coroner, urging a more cooperative, multi-agency approach to support planning. Catherine Cundy emphasized that a coordinated, multi-agency response might have produced a more appropriate and comprehensive support plan for Ms Taylor, and she urged mental health services to work together to prevent similar deaths in the future.

In a statement accompanying the inquest, Emma Worden, describing her sister’s death as the result of systemic neglect, underscored the human impact of the case. The coroner’s findings highlighted the tension between crisis-and-acute-level assessments and the longer-term needs associated with trauma recovery, and they called for improved collaboration among healthcare providers to ensure that individuals with complex needs receive ongoing, trauma-informed care rather than isolated, time-limited interventions.

Ms Taylor’s case illustrates broader concerns about how crisis services, primary care, and secondary mental health teams coordinate care for individuals with co-occurring mental health and substance-use issues. The coroner’s recommendations aim to trigger policy and procedural changes that would facilitate earlier identification of risk factors, more consistent care pathways, and timely access to trauma-focused therapies for patients who, like Ms Taylor, are navigating the long aftermath of childhood trauma and post-natal depression.