A school dinner lady took her life after becoming convinced that she had harmed a child with allergies by mixing up the food bags given to pupils.

The case has been highlighted following an investigation by the Mental Welfare Commission (MWC) for Scotland which found that there were "missed opportunities" to prevent the woman's death in April 2021.

The woman, known only as Mrs F, was in her 50s with a grown-up daughter.

She lived with her husband, with whom she had been in a relationship for 40 years, and worked part-time in school catering.

Mrs F had no prior history of mental health problems, but in April 2021 her husband - Mr F - had woken up to discover his wife sitting in their living room fully dressed "saying that she needed to go to the police station to report that she had harmed a child".

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Mrs F told her husband that she had mixed up food bags for the children at her work the week before, and feared that one of the children with food allergies had been harmed as a result.

The MWC report said that Mrs F went on to tell her husband that she "was worried that the child’s parents and hit men were coming to harm her and her family and that they would lose their home to pay for legal fees".

Mr F drove his wife to their nearest emergency department where she was triaged as "high risk" and seen by a consultant.

Mrs F revealed to the doctor that three days earlier she had tried to end her life by consuming an overdose of tablets, and when this failed had attempted suicide using a ligature.

When this was unsuccessful, she kept the self-harm a secret from her husband.

Mrs F spoke to the consultant "at length about her concerns that she had given a child at school the wrong food".

The report notes that she "could not give any objective evidence regarding this, nor could she be reassured that it was unlikely anyone had come to harm".

Blood tests, an ECG and a physical examination established she had not suffered adverse effects from the recent drug overdose.

The Herald: The MWC report does not disclose in which health board area the events involving Mrs F unfoldedThe MWC report does not disclose in which health board area the events involving Mrs F unfolded (Image: PA)

The consultant referred her via telephone to the local Mental Health Assessment Unit (MHAU) due to "ongoing suicidal thoughts and intent".

Mr F - who had been waiting in the reception area due to Covid restrictions - was brought in and told that there were serious concerns for his wife's mental health.

Mr F drove his wife directly to the MHAU where he "fully expected her to be admitted to a psychiatric ward".

However, the nurses who evaluated Mrs F found her to be "calm and appropriate" throughout her assessment, concluding that she was not "experiencing psychotic symptoms or at risk of further harm to herself".

She denied being suicidal and insisted the overdose had been "impulsive".

They said Mrs F appeared "reassured that it was unlikely that any harm had come to the children".

Mrs F "made it clear that she did not want her husband involved in her assessment" and the nurses told MWC investigators that they "did not have clear reasons to breach her confidentiality".

Mrs F was discharged back to her GP without any follow-up care planned, and Mr F said he felt they were "rushed out of the unit".

The following day Mrs F spent time with her husband in their garden, made him his favourite dinner, and spoke to her daughter for a long time on the telephone making plans to visit.

Her daughter told the MWC that it felt as though her mother had "made a real effort to make this a perfect last day".

The Herald: The MWC said Mrs F should have been diagnosed as suffering from a mental illnessThe MWC said Mrs F should have been diagnosed as suffering from a mental illness (Image: PA)

The next day, Mr F returned home from work to find his wife dead in the bathroom from self-inflicted knife wounds.

The MWC said that Mrs F should have been diagnosed as suffering from mental illness, and that families and carers "should be involved wherever possible in mental health assessment and treatment processes". 

The investigation highlighted a lack of staff training within the MHAU at the time of Mrs F's presentation.

Delays in uploading important documents from her emergency department assessment onto the electronic record also meant that the MHAU assessment was "limited from the outset" by a lack of information.

This was exacerbated when Mr F was not given an opportunity to speak with the nurses "to share highly relevant information" about his wife's symptoms. 

The MWC report concludes: "Whilst it is right that consent should be sought from patients to share their information with others, including family members, this should not act as an impediment to listening to the concerns of carers and family members; and where possible involving them in care planning and safety planning."