Failed by the system

The suicidal 22-year-old was helped to die by her father in a mercy killing in 2000 after suffering more than 10 years of manic depression.

James Lawson, 55, helped her take a drug overdose and then suffocated her at the family home in Georgia Avenue, Broadwater. He walked free from court in 2001 after pleading guilty to manslaughter.

The family said the NHS repeatedly failed to help their daughter and have been calling for an independent inquiry for almost four years.

This week, a costly and critical independent "review" was published, which said Miss Lawson's treatment was "fragmented" and found "failings" in the supervision and management of workers responsible for her care.

The report, commissioned by Surrey and Sussex Strategic Health Authority and West Sussex County Council, said at the early stages of Miss Lawson's care "it would have been difficult to envisage a more unsatisfactory situation".

Miss Lawson's parents wanted their daughter to be admitted to a secure psychiatric unit after a series of suicide attempts. In April, 2000, she was taken to Homefield in Worthing but was discharged after she was found in possession of cannabis. Six hours later, Mr Lawson killed her.

The main findings of the report published on Monday are:

The Worthing Community Mental Health Team was dysfunctional in August, 1997, when Ms Lawson was referred to it and by early 1998, her treatment was fragmented.

Information was not communicated to the community mental health Team.

The Lawson family's needs were not adequately assessed and steps were not taken to address the separate needs of Sarah Lawson and her parents as carers.

There were failings in the supervision and managements of clinicians in in the Worthing Priority Care Trust.

On occasion, Sarah Lawson's mental health was influenced negatively by her parents, and especially her mother Karen Lawson. In the absence of community mental health team involvement, Karen Lawson became the driving force of her daughter's care. It was she who objected to, proposed, and rejected various treatments.

Ms Lawson was not examined before she was discharged from Homefield. Had the doctor been in possession of the full facts, he would not have recommended discharge.

The report also criticised the Lawsons for not disclosing "relevant" information about their own background and not giving evidence to the review panel.

Mr Lawson said on Monday the family was horrified by suggestions they had made their daughter's illness worse.

Health bosses said the service had undergone root and branch changes since Miss Lawson's death.

Lisa Rodrigues, chief executive of West Sussex Health and Social Care NHS Trust, which has replaced Worthing Priority Care and its services, said: "We have learnt the lessons arising from this review and have made substantial service changes during the past four years.

"Health and social care in Worthing has undergone root-and-branch reform since Sarah's death."