Oxfordshire dad comments on Cherwell Valley services death

Willow du Plooy, 21, who had suffered from serious mental and physical ill health since adolescence, took an overdose of opioid-based pain medication she had bought over the internet.

She was found in a room at the Travelodge hotel at the M40 Cherwell Valley services between Bicester and Banbury on the evening of November 28, 2021, and had written 11 ‘suicide notes’ that were dated November 6.

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Miss du Plooy’s father, Leon, hit out at what he described as ‘failures’ in her care by NHS mental health services.

He told her inquest on Tuesday (March 14): “It could have been prevented. It should have been prevented.” 

Oxford Coroner’s Court heard that the young woman had been reported missing earlier that day by staff at Oxford Health NHS Foundation Trust, whose community team was supporting her after she was discharged from the Warneford Hospital on November 2.

Their last contact with her was by phone on November 27, when she apologised for missing an appointment earlier that day and said she had been seeing friends in Oxford.

A police investigation later established that she had checked in to the Travelodge shortly after midday, arriving in a minicab that had been booked the day before.

• For support with mental health, contact the Samaritans on 116 123 or visit www.samaritans.org. In a mental health crisis you should contact the emergency services by calling 999 or call 111 for the 24/7 Mental Health Helpline.

Her inquest heard that in the week before her death Miss du Plooy told clinicians and staff at her supported accommodation in Banbury that she planned to take her own life.

After learning that she may have ordered non-prescribed medication online, Oxford Health staff were said to have contacted Royal Mail and Thames Valley Police to try and get the parcel intercepted. Seemingly, neither were able to help.

The Warneford, Oxford, where Willow du Plooy was a patient from October 19 until her discharge on November 2

Senior coroner Darren Salter said he would consider whether to write to Royal Mail and the Home Office following the inquest about the difficulties faced by Oxford Health in trying to get the illegal medicine it was suspected had been ordered online intercepted by the police and postal service.

Mr Salter accepted the explanations of Oxford Health doctors that it would not have been appropriate to detain Miss du Plooy under section three of the Mental Health Act – despite her expressing a ‘concrete plan’ to take her own life.

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Consultant psychiatrist Dr George Theodoulou, who oversaw her support in the community after she was discharged from hospital on November 2, saw her a few days before her death.

She talked to them of having a plan to kill herself, but would not give any details. He concluded following that meeting that she was a ‘high risk of death by misadventure’.

However, he told the inquest that detaining her under section three of the Mental Health Act would have been ‘probably unlawful’.

Two doctors and a third official, who would be the one to recommend detention in hospital, would have to be satisfied she was a risk to herself or others and that appropriate treatment was available in hospital, the inquest heard.

Willow du Plooy

Miss du Plooy had only just been discharged from an almost four month stay in two institutions, including an out-of-area acute psychiatric unit in Potters Bar where she had self-harmed and the police were called after she alleged a staff member hit her with keys in retaliation for being kicked.

There was evidence that those with the personality disorder with which she had been diagnosed did not respond well to being kept in acute psychiatric inpatient wards, Dr Theodoulou said.

READ MORE: Tributes paid by family to tragic Willow du Plooy

He added: “The decision had been made that detention in an acute hospital under section three was no longer appropriate and I think for me to have then made a medical [referral] under section three in the face of the overwhelming evidence and consideration that was documented didn’t sit right with the therapeutic plan.”

No ‘appropriate treatment’ would have been available in hospital, he said.

Miss du Plooy was due to start therapy treatment days after her death and was receiving support at a ‘day hospital’ in Banbury and from the community team.

Various clinicians within Oxford Health had reconsidered the position after Miss du Plooy, who had made a number of previous attempts on her life earlier in the year, shared thoughts of suicide – but it was decided to keep to the plan drawn up on her release from the Warneford.

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The young woman’s father, Leon du Plooy, told his daughter’s inquest: “I believe that if it is unlawful to detain somebody that is clearly a risk to herself that law needs to be changed; that law is wrong.

“It is a shame the adult mental health system in this country is governed by cycles of bureaucracy that means that three professionals need to agree…before somebody can be stopped from taking their own life.”

He added: “It could have been prevented. It should have been prevented.” He said there had been a ‘cacophony of failures’ in his daughter’s care.

Mr du Plooy said the mental health trust had told him that they intended to name a ‘therapeutic home for young adults in the same situation’ in Willow’s memory. “What an insult,” he said.

The coroner ruled Miss du Plooy’s death was suicide.

• For support with mental health, contact the Samaritans on 116 123 or visit www.samaritans.org. In a mental health crisis you should contact the emergency services by calling 999 or call 111 for the 24/7 Mental Health Helpline.