Teacher walked into river after failing to get help from mental health service

Teacher walked into river after failing to get help from mental health service A coroner has filed a report in a bid to prevent future deaths The family of a former teacher who died in a river say she was let down by mental health services. after being unable to access medication or the support she needed. Carolyn Groom went missing from her home in Northfleet, Kent, at around midnight on April 7, 2025. Dozens of people helped her family search for her over the following weeks before the 76-year-old’s body was found at Town Pier in Gravesend town centre on April 24. An inquest into her death has now been held in Maidstone The court heard how, in the lead-up to her disappearance, the family had been trying to get her back on antipsychotic medication. She had lived with the illness for more than 50 years and had previously taken amisulpride. But from July 2022, the former teacher and secretary was weaned off the drug because she had high levels of prolactin – the hormone that produces breast milk in women. After a couple of months coming off the medicine, her mental health began to get worse. In the year before she died, it declined dramatically. Mrs Groom’s family took her to a GP on February 28 after seeing signs of her psychosis returning. The doctor referred her to Kent and Medway Mental Health Trust (KMMHT) The assessment said she was suffering from “low mood” and also noted that her family had concerns about what they described as psychotic behaviour. It was not marked as urgent because the doctor found she was not displaying signs of wanting to take her own life, or to harm herself or others. On March 4, Gill Mangeet, a KMMHT clinical pathway lead who had worked with the family before, booked an assessment for within 28 days. Ten days later, Mrs Groom’s GP requested that the appointment be brought forward because she was rapidly deteriorating. The family said that by this time she was convinced that the government and people in power wanted to kill her and that special messages were being sent to her in TV programmes and over the radio. These concerns were sent to KMMHT. On March 27, she was seen by an assistant psychologist who found that Mrs Groom again did not show signs that she wanted to commit suicide, or that she wanted to harm herself or others. But her husband, Frank Groom, said she was showing signs of delusion and handed the doctor a bundle of papers with his wife’s background of mental health issues. He also said that she was masking her psychosis when being assessed – something Mrs Groom had done before as she knew it would stop her having to go to hospital. Following the assessment, another clinical pathway lead at KMMHT, Harry Chatory, reviewed her case and arranged another assessment for April 22. Coroner Sarah Clarke asked why there seemed to be a lack of urgency for a follow-up appointment for Mrs Groom. Mr Chatory said this was because there was “no evidence of psychosis as she did not voice any suicidal thoughts or risk to herself or others” in the report. However, he did say things should have been done differently and that Mrs Groom should have been "seen as soon as possible” due to her history of psychosis. The grandmother of eight cancelled the appointment on the day she went missing from her home on April 7. No contact was made with her family about the cancellation. Mrs Groom walked to her favourite place, Gravesend Promenade, and then into the River Thames. Her medical cause of death was given as part 1a: drowning and part 2: paranoid schizophrenia. Concluding the inquest, Miss Clarke said the Trust had failed to show urgency in treating Mrs Groom, despite her long history of psychosis, declining mental health and her family’s concerns. She also said there had been a lack of support from the Trust for Mrs Groom while she was waiting for assessments and not enough contact with the family. Miss Clarke added that she would lodge a prevention of future deaths report. The mother of four left behind her daughters Abigail, Jemima, and Miranda, her son David, and her husband Frank, who she had been married to for 33 years. After the inquest, the family said they believe she would still be alive if the trust had acted more quickly and hope changes will be made to the system. In a statement, they said: “Hearing about failures in the system was heartbreaking. We believe mum’s death could have been prevented had she been seen quicker by a psychiatrist. We also feel that a return to a different anti-psychotic medication would have helped her improve and avoided her death.” The family feel their concerns were not taken seriously by the mental-health team. “We repeatedly felt that what we were seeing and saying about mum was not being given the weight it deserved,” they added. “We are the people who lived with mum, and we knew her, and we knew her history. “We knew the difference between mum being herself and becoming unwell. We also knew that people with mental illness can often mask how they are feeling or how unwell they really are in front of others, including professionals. “Sometimes a professional asking a very mentally unwell person if they are okay is not going to result in being given a full and clear picture. We weren't asking for special treatment for mum; we were asking for someone to recognise how seriously ill she was and to respond to her as an urgent case.” A spokesperson for Kent and Medway Mental Health NHS Trust said: “We are deeply sorry for the loss of Mrs Carolyn Groom and send our heartfelt condolences to her family and friends at this very difficult time. “We know how distressing the inquest will have been for everyone who knew and loved her. Following the conclusion of the inquest, we will provide the coroner with further information about the changes and improvements we are making to our services. Our thoughts remain with Carolyn’s family and loved ones at this time.” Paying tribute to Mrs Groom, her family said: “Carol was so much more than her illness. She was an intelligent woman who had once been a teacher and secretary, mum, wife, and grandmother. She was a loving and caring woman who was a really strong person. “She loved going on walks at the Promenade, where she must have spent decades of her life. Carol loved seeing friends and her family and took great joy in being a grandmother.” The family has a memorial bench for Mrs Groom at Gravesend Promenade, which overlooks the River Thames. The plaque reads: “She found peace where she once found joy. Forever a part of the shore.”