Newlywed who jumped to her death in Hackney had been sent home from hospital hours before
- Credit: Supplied by Mariana's husband
A newlywed plunged to her death from the third-floor balcony of her home only hours after doctors considered it safe for her to leave the Homerton Hospital.
Spa manager Mariana Pinto was released home less than 24 hours after she was handcuffed and taken to A&E strapped to a stretcher for her own safety due to her erratic behaviour.
A mental health crisis team also failed to bring forward a visit to see the 32-year-old or ensure emergency services were called when her “rapidly deteriorating” mental state was reported.
Husband Camilo Parra-Braun, who married Mariana in June 2015, criticised mental health services for failing her, during an inquest into his wife’s death at Poplar Coroner’s Court on Monday.
In a statement read out in court, he said: “Mariana was a force of nature, a divine soul who burned so very brightly and touched so many lives.
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“She never once talked about ending her life and I am certain she did not intend to. She was planning her future – our future.
“We feel the professional help that we tried to get for Mariana was totally inadequate and I am left with many questions about it.”
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Mariana had suffered a serious breakdown at her home in Westgate Street, Hackney, on October 15.
The court heard she had used cannabis regularly over the last five years but had stopped a few days before and was having trouble sleeping and feeling anxious.
The day before she died, Mariana’s behaviour became “erratic, paranoid, confused and frightened” as she persistently tried to escape the flat in the mistaken belief her sister, who was in Brazil, was outside.
Police were called and Mariana was restrained for her safety and taken to the Homerton by ambulance.
The court heard she was given the drug Lorazepam to calm her symptoms and doctors decided she was not at sufficient risk to be sectioned under the Mental Health Act. She refused a voluntary admission and was allowed home with medication.
Psychiatrist Dr Juliette Brown, who assessed Mariana at the Homerton, said she believed she was suffering from cannabis withdrawal and an underlying anxiety condition unmasked by ceasing cannabis use.
The following day on Sunday, October 16 Mariana’s mental state spiralled again.
At 3.30pm her husband rang the City and Hackney Crisis Resolution and Home Treatment Team and said he needed somebody to come urgently as Mariana was “deteriorating rapidly”.
The mental health nurse who took the call, Admire Mukotekwa, said visits were from 5-7pm and told him to “get another ambulance or police and call to A&E”.
The team did not leave to visit Mariana’s flat until 4.30pm and arrived 10 minutes later to find a police cordon already set up around the property, he told the court.
Mariana had jumped from the balcony of her third floor flat at 4pm.
She landed on a glass roof and lay there impaled before rolling and falling into a basement courtyard below.
Senior coroner for inner north London Mary Hassell asked Mr Mukotekwa: “Do you think you should have come off the phone and said ‘We need to get two people over there right now’. Should you have done that?”
He replied: “In hindsight yes, but at the time I was very mindful of how many other clients we had to see.
“Also I was thoughtful about how much are we going to be able to help if the patient needs to be restrained. So yes in hindsight I think we should have attended.”
The court heard cuts to the service meant home visits were no longer carried out on Saturday nights or Sunday mornings.
The coroner returned a narrative verdict which said Mariana’s actions were deliberate but the 32-year-old “did not have the necessary understanding to categorise the death as suicide”.
She said she would write a “prevention of further deaths report” recommending changes in care.
She told Mariana’s family and friends in court: “The one thing I don’t know is if things had been different in terms of the way her crisis was responded to whether the outcome would have been different.
“I don’t have that information and I can’t say to you that it would have been. I can only say that there is an opportunity to do things differently in the future.”
Andrew Birkett, who carried out a serious incident review for East London NHS Foundation Trust, said a number of changes had already been made.
After the verdict, legal representative for Mariana’s family, Grainne Barton, a partner at law firm Hugh James, said: “The driving force for the family was that lessons will be learned and things will improve and another family won’t be put in the same position.”