AN overhaul of mental health services in North East Lincolnshire has followed the tragic death of a much-loved schoolteacher.

Jane Owen (38), who taught for many years at Monks' Dyke Technology College, Louth, was found by her father at her home in Humberston Road, Tetney, in June last year, an inquest heard.

A post mortem examination revealed she died from hanging on June 3. Louth district coroner Stuart Fisher recorded an open verdict.

The inquest heard that Miss Owen had suffered mental health problems with anxiety and depression and was treated with the drug librium for two years.

But medical experts at the inquest at Horncastle Register Office said she should not have been treated for so long with librium.

They described the drug as "highly addictive", which required a managed withdrawal.

Her Beacon Surgery GP, Dr Tim Bruning, said: "It should have been reviewed. She never made the review and no one thought to chase it up.

"It was due to withdrawal, but also connected to her pre-morbid state. It may have contributed to her taking her own life."

North East Lincolnshire's assistant director of mental health operations, Barry Flintoft, said: "Lessons can and will be learned from this serious untoward investigation of systemic failure."

He announced a series of measures which will avoid a repeat of the tragedy. They include an overhaul of the Care Programme Approach. Extensive training is underway for all care co-ordinators.

In future, all cases must have a care co-ordinator, especially for "borderline personality disorder" patients such as Miss Owen.

Mr Flintoft said a policy of clinical risk management in mental health was in force as a result of the case, and added record keeping would be improved. All measures have been approved by the Care Trust Plus Board.

Before recording the verdict, Mr Fisher said: "I do not recall any case I have been involved in as coroner where there has been such a clear acceptance of criticism by a health authority.

"Mr Flintoft put forward a raft of recommendations that have been put in place to prevent similar occurrences in the future. I have read these most carefully and support each and everyone of them."

Dr Ronnie Sealant, a clinical and forensic psychologist, admitted Miss Owen's case had not been followed up despite her being invited to fill in a form to undergo mental health treatment at the Diana, Princess of Wales Hospital, Grimsby.

She said: "We have an enormous number of people who do not reply. We are 50 per cent understaffed."

There was the equivalent of two-and-a-half full-time members of staff, she said, adding: "Two-and-a-half psychologists can't do everything."

Miss Owen's father, Douglas Owen, of Hilton Court, Cleethorpes, catalogued his daughter's mental health problems and said treatment had gone "from a first rate service to none at all and fell flat".

Describing the care he, his wife and Jane's brothers gave, Mr Owen said: "It seemed as if we were on our own."

Practices will adopt new guidelines - read more here.