A MENTAL health trust blunder which ‘contributed’ to the death of a Halesowen woman has been slammed as “totally unacceptable” by one of the trust’s bosses.

Depression and anxiety sufferer Katarzyna Woloncewicz, known as Kasia, took her own life on March 29 – one month before her 21st birthday.

But during an inquest at Black Country Coroners Court, assistant coroner Emma Whitting adjudged failings by Dudley and Walsall Mental Health NHS Trust (DWMH) to have contributed to her death.

Kasia was initially advised to make a self-referral to Dudley Talking Therapy Service (DTTS) – which is operated by DWMH – following a mental health assessment at Dudley’s Bushey Fields Hospital on February 1.

Phone records confirmed the 20-year-old made a one minute, 20 second call to the service on February 2, but only got through to an answerphone message.

The message said if she left her name and phone number someone from DTTS would get back to her – but they never did.

The same thing happened when she made a second call on March 7.

Her mother Jayne McCracken said she believes her daughter would still be alive if DTTS had returned her calls.

Following Kasia’s death, DWMH’s joint medical director Dr Mark Weaver carried out a thorough serious incident investigation review.

Speaking in court, Dr Weaver said the lack of contact Kasia received from DTTS was “totally unacceptable” and his investigation is set to lead to a whole scale review of the trust’s provision.

He said: “We are constantly looking into improvements we can make.

“There's always something we could have done better, even in times when you’ve done everything right.”

Giving a conclusion of suicide, Ms Whitting said: “My heart goes out to all of her family, but particularly her mother, who has not only had to deal with this terrible event of the loss of her daughter, but has also had to fight for her questions to be answered, and for the appropriate lessons to be learnt as a result of Kasia’s tragic death.

“Clearly there were system failures in the mental health service which let Kasia down at her time of need.

“This has now been recognised by the trust.

“I’m grateful for Dr Weaver in explaining how he would personally take the lead in making sure this whole scale review of the trust’s provision is carried out and the lessons learnt from Kasia’s deaths are translated into effective change to minimise risk of further similar devastating tragedies occurring the future.”

Following the inquest, a spokesman for Dudley and Walsall Mental Health Partnership Trust said: “The death of Katarzyna Woloncewicz was a very tragic event and we would like to repeat our sincerest condolences to her family.

“We have completed a thorough investigation and as a result we will be making improvements to the way we respond to patient referrals and reviewing the effectiveness of our Mental Health Assessment Service. We are also addressing the way in which we respond to self-referrals to our Talking Therapies Service.

“We support and care for many people in crisis and we take learning from all incidents seriously so we can continuously improve the care we provide for patients.”

A family statement issued to the News by Mrs McCracken said: “She did not receive the help and support she needed and, as a result, Kasia’s family and friends will have to live with this tragedy for the rest of their lives.

“As her mother, my opinion will never change that Kasia was failed by Dudley and Walsall Mental Health Partnership Trust.

“And I hope as a result of the inquest, and support of our MP James Morris – who is due to meet with the trust’s CEO – that the trust learns lessons from Kasia’s death and implements changes to their inadequate processes and procedures to ensure that no other family suffers the loss of a beloved child.”