A WORLE mother, who lost her father, sister, brother and son to suicide, may not have killed herself if mental health teams had communicated better, an inquest was told.

Elizabeth Treasure was found dead at her home just a day after being discharged from Weston General Hospital after a week-long stay, following a second failed suicide attempt in three weeks.

Her husband Andrew said he raised concerns over a doctors’ decision not to section her as it was revealed staff at Avon and Wiltshire Mental Heath Trust (AWMHT) had disagreed on whether she should be allowed to go home.

He said: “In the last four weeks her mental health deteriorated quite badly.

“I believed they were serious (suicide) attempts and I thought it was most likely to happen again. I was worried Elizabeth would take her own life by design or accident.”

Mrs Treasure’s father Alan committed suicide when she was aged 22 and her brother Billy four years later. Her sister Sally-Anne and son Richard also took their own lives when Mrs Treasure was aged 39 and 44 respectively.

Mrs Treasure then worked as a bereavement counsellor for Survivors Of Bereavement By Suicide in a bid to help others in a similar position. However, her mental health deteriorated in 2011 and she received regular care from a personal assistant and doctors.

Care co-ordinators from the AWMHT would regularly visit her and had been told to use an unlocked side door.

Mrs Treasure made two attempts to take her own life in November 2011, the second of which saw her stay at Weston General Hospital for a week. On November 30, she was discharged and allowed to return home with daily checks by the crisis mental health team.

Two doctors had disagreed over whether to section Mrs Treasure but it was decided she did not fit the legal criteria for involuntary sectioning and it would be reassessed daily by the crisis mental health team.

Social worker Linda Rihan was part of the two-strong team which went to visit Mrs Treasure at her Becket Road home on December 1, 2011.

She assumed the 62-year-old was not at home after getting no reply when she rang the doorbell, knocked on the door and got a colleague to call the home phone. There was no sign of anyone inside when she peered through the window.

Mrs Rihan told the inquest she was ‘completely unaware’ of the arrangement concerning the kitchen door.

She said: “We got back in the car and drove back to Weston General Hospital where we are based. On this occasion I really felt there was something wrong. It was a gut feeling and that’s why I called the police (once back at the hospital).”

Police officers arrived at the house shortly after 4pm and Mrs Treasure was found dead on the sofa.

Ms Rihan admitted there had ‘possibly’ been a breakdown in communication between departments when Mr Treasure quizzed her on why she did not try the side door.

The 61-year-old, who was joined by Mrs Treasure’s daughter, Sheryl Andrews, told the inquest: “I feel very let down by their actions on the day. Had they made a better effort to make access on the day then I feel Elizabeth would still be alive.”

Assistant deputy coroner Terence Moore said Mrs Treasure had committed suicide by asphyxiation.

He said: “Mr Treasure had a very natural hope that someone visiting the house would have tried the side door and probably prevented this tragic death.

“But I don’t seek to blame anyone. Judgements were made on the basis of information known and I don’t think any criticisms can be made.

“By not answering the door it seems she had made a decision not to talk with the mental health team.

“It appears a conscious decision and it is on that basis that I think I can be satisfied beyond all reasonable doubt that she took her own life.”

Dr Julie Hankin, a consultant psychologist for AWMHT, said steps had been taken to improve communication between departments since Mrs Treasure’s death.

Following the inquest Mr Treasure paid tribute to his wife of more than 20 years, describing her as a devoted charity worker who was always willing to help others.