Most people would have strong feelings if their own flesh and blood stabbed them three times in the chest and belly. Not Anette Trotman. “I have never once felt anger towards Diana or blamed her for attacking me,” she said after an inquest into the death of her daughter Diana Grant. The 42-year-old from Willesden took her own life just a day after arriving at HMP Bronzefield prison in Surrey.
Diana’s tragic death sparked an investigation by the Prison and Probation Service Ombudsman, which found multiple failures by the prison, while a jury inquest also found a number of failings by the health service that contributed to her death. The coroner is set to write a Prevention of Future Deaths report, addressing what Ms Trotman has called ‘a shocking catalogue of failures’.
In their conclusions, the jury said there were ‘numerous opportunities’ for a mental health assessment, which might have led to a hospital admission rather than prison, and that community healthcare failures in the days leading up to her arrest also ‘possibly contributed more than minimally to her death’.
The inquest heard Diana had been under the care of the Community Mental Health Team for 20 years and had been diagnosed with schizophrenia. Despite her struggles her family say she enjoyed life, studied business at university, worked as a chef and ran her own car valeting business. Sadly, she would occasionally relapse with worsening delusions.
In the days leading up to her death, Ms Trotman became concerned she was relapsing and referred her daughter to the CMHT on November 12, but no action was taken. Then on November 17, Ms Trotman took Diana to the Brent Community Mental Health Centre but they left without being seen by a specialist. A few hours later Diana stabbed her mum three times in the breast and stomach.
When Ms Trotman called police, she had hoped they would take her to hospital for mental health treatment, but instead she was arrested for attempted murder and escorted to St Mary’s Hospital in Paddington.
Speaking through Hudgell Solicitors, Ms Trotman said: “I have never once felt anger towards Diana or blamed her for attacking me. That was not her, she was not in control of herself. It was a shocking catalogue of failings by state services that failed her completely when she needed their help at a point of crisis. I am truly devastated by her passing.
“She lived and breathed for her beloved daughter, and she tried her best to keep up with the challenges that the world gave her, yet she lived what most would agree to be a full life of love, self-expression, hardships, and accomplishments.
“I will remember her for all the good she did and despite all the challenges with her struggles and mental health, she was loved unconditionally. The early morning visit by the prison staff to inform me of her death will haunt me forever.”
The inquest heard how officers were concerned about her health and thought she needed a mental health assessment, but that one never took place due to a ‘tug of war’ between senior police officers and the hospital consultant. The consultant refused to do one, despite clear NHS England guidance, so Diana was discharged and taken to Colindale Police Station.
In custody she got no assessment, and was interviewed the morning after the stabbing and charged with attempted murder. After appearing in Willesden Magistrates Court, she was remanded to HMP Bronzefield. Recognising her mental health risk, the court alerted the prison, but no dedicated support plan was put in place and she was found dead the next day, having died by suicide.
‘She wanted her to be cared for’
Iftikhar Manzoor, of Hudgell Solicitors representing Diana’s family at the inquest, said: “Ms Trotman had spent many years witnessing the impact of her daughter’s mental health on her life and her behaviour, and she knew when medication was no longer working effectively, when Diana was showing concerning signs of relapse, and when she needed reassessing and help.
“Twice within a space of a week she sought that help for Diana when she was displaying clear signs of relapse and it was not forthcoming, the second time being just hours before Diana lost all control of her mind and attacked her with a knife, stabbing her three times.
“These were the key opportunities to check on her condition and ensure her mother’s concerns were referred to a treating consultant urgently, or to arrange for Diana to be seen and assessed by a psychiatrist urgently. Had this happened, she would have been treated and monitored as necessary, including through voluntary admission to hospital or by arranging a Mental Health Act Assessment.
“From that point onwards, Diana’s mental health spiralled out of control, leading to the attack on her mother. When Ms Trotman called the police that day, she believed she’d be given the treatment she required. She didn’t want her charged with attempted murder; she wanted her to be cared for.
“When she spoke to the police the next day, she expressed her concerns at this and said that her daughter was sick and required medical help, but around 10pm that night she got a call to say Diana was to be charged with attempted murder and was to be in court the next morning.
“Two days later she had a knock on the door, and it was staff from the prison, who told her that her daughter was dead. This was just three days after she’d taken her daughter to the mental health clinic at crisis point, seeking help, which was simply not forthcoming.”
You don’t have to suffer in silence if you’re struggling with your mental health. Here are some groups you can contact when you need help.
Samaritans: Phone 116 123, 24 hours a day, or email [email protected] in confidence
Childline: Phone 0800 1111. Calls are free and won’t show up on your bill
PAPYRUS: For teens and young adults. Phone 0800 068 4141
Depression Alliance: The charity offers useful resources for people struggling.
Students Against Depression: For students who are depressed, have low mood, or are suicidal.
Campaign Against Living Miserably (CALM): Phone 0800 58 58 58. For young men who are feeling unhappy.
James’ Place: Offering life-saving treatment to suicidal men in London and surrounding area.
For information on your local NHS urgent mental health helpline, visit here
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