Systemic Failures in Women’s Mental Health Care: Why Context Matters

By Ying Xue

A recent inquest reported by The Guardian concluded that Michelle Sparman, a 48-year-old woman admitted to a psychiatric ward in south London, died by suicide following neglect within the mental health system. The coroner found that despite clear “red flags” indicating risk, fundamental safeguarding practices were not followed. Inadequate searching procedures, the absence of proper record-keeping, and fragmented institutional responsibility contributed to her death.

This case is not simply a tragic individual story. It exposes systemic and wholesale failures in women’s mental health care. Failures that arise when institutions treat women’s distress as an isolated pathology, rather than as something shaped by lived realities, relationships, social pressures, and structural inequality.

Too often, women’s mental health is framed as the outcome of individual vulnerability, biological change, or personal weakness. Anxiety, depression, impulsivity, or perimenopausal symptoms are listed as causes, while the social contexts that intensify distress are treated as secondary or incidental. This approach not only limits understanding, it actively undermines care. A feminist perspective challenges this narrow framing by insisting that women’s mental health cannot be separated from the conditions in which women live.

How Abuse Shapes Women’s Mental Distress

For many women, mental distress develops within environments marked by abuse. Physical, psychological, emotional, and economic abuse are all deeply connected to anxiety, depression, trauma responses, and suicidal ideation. Yet in practice, abuse that women experience is often ignored and, sometimes difficult to define and name.

Women’s experiences of abuse do not always align with legal thresholds or institutional checklists. Control, coercion, harassment, surveillance, and intimidation may be ongoing without a single identifiable incident. Feminist scholars describe this as a continuum of violence, where harm accumulates over time rather than appearing as a discrete event.

This is why survivor self-definition matters. Women are often the first to recognise that something is wrong, long before systems acknowledge it. When women describe feeling trapped, unsafe, or diminished within a relationship, those feelings are not secondary to clinical assessment. They are critical sources of knowledge. Ignoring them risks missing the very conditions that shape mental distress.

Mental health care that fails to engage with women’s own understandings of their experiences risks misreading distress as irrational, excessive, or purely internal. In doing so, it reproduces harm.

Caring for Women’s Mental Health Across Levels

Responding meaningfully to women’s mental health requires action at multiple levels.

At the individual level, women need validation rather than dismissal. Trusting one’s own feelings, recognising distress as meaningful, and seeking support without shame are essential steps. Women are often socialised to minimise their own pain, to accommodate others, and to doubt their perceptions. Mental health care should actively counter this pattern, not reinforce it.

At the couple or relationship level, it is vital to acknowledge women’s subjectivity. Women’s emotional boundaries, autonomy, and interpretations of harm must be respected. Relationships that undermine confidence, generate fear, or erode well-being should never be dismissed as “difficult” or mutual without careful attention to power dynamics.

At the institutional level, the responsibility is even greater. Mental health services must move beyond individualised models of distress and adopt approaches that recognise gendered power, inequality, and violence as central to women’s mental health.

Feminist Principles in Mental Health Care

There is substantial evidence showing that women’s mental distress is closely linked to social factors. These include intimate partner abuse, economic insecurity, caregiving burdens, housing instability, workplace inequality, racism, migration status, and social isolation. Yet these factors are often marginalised in clinical practice, particularly where pharmacological treatment dominates.

Medication can play an important role, but when it becomes the primary response, social causes are obscured. Women’s distress is treated as something to be managed chemically rather than understood relationally and structurally.

Elaine Tseris, in her article Placing women’s mental health in context: The value of a feminist paradigm, argues for a shift away from narrow biomedical models towards a feminist framework that situates women’s mental health within broader social realities. Tseris highlights several principles that are particularly relevant. Feminist mental health care:

• Prioritises validation and non-judgment. Women’s accounts of distress are taken seriously, without pathologising their responses to harm.

• Makes explicit connections between mental health and social context. Distress is understood as shaped by relationships, environments, and systems, not simply by individual psychology.

• Addresses the social determinants of mental health. Poverty, housing insecurity, violence, discrimination, and unpaid care work are not peripheral issues. They are central drivers of mental distress.

• Recognises the complex reasons why women may appear reluctant to access support. Fear of not being believed, prior negative experiences with institutions, cultural stigma, and practical barriers all influence help-seeking.

• Ensures agency and choice. Women are not passive recipients of care but active participants in defining their needs, goals, and pathways to recovery. Multiple understandings of distress and healing are respected, rather than imposing a single model of “recovery”.

  
  

Why Systemic Change Is Necessary

The case of Michelle Sparman highlighted by the coroner demonstrates what happens when systems fail to hold context. Safeguarding becomes procedural rather than relational. Risk is assessed without truly understanding the person at the centre of care. Responsibility is fragmented, and accountability diluted.

Systemic wholesale failures occur when women’s mental health services are not designed around women’s lives. When distress is abstracted from abuse, inequality, and social pressure, institutions may comply with policy while failing in practice.

A feminist perspective does not remove individual responsibility or clinical expertise. Instead, it strengthens them by grounding care in reality. It asks not only what symptoms a woman presents with, but what has happened to her, what she is navigating, and what structures have failed to protect her.

Rethinking Care, Responsibility, and Women’s Lives

Women’s mental health cannot be safeguarded through checklists alone. It requires systems that listen, believe, and respond to women’s lived experiences. The tragedy of Michelle Sparman’s death is not only a failure of procedure, but a failure of perspective.

Reframing women’s mental health through a feminist lens is not an academic exercise. It is a necessary shift if we are to prevent harm, restore trust, and create care that genuinely supports women to survive and heal.

Systemic change begins when we stop asking why women are unwell, and start asking what has been done to them, what they are carrying, and how institutions can do better.