Coroner's letter to be sent to failing health trust calling for changes after suicide of 22-year-old
PUBLISHED: 07:30 05 April 2019
A failing mental health trust will be issued with a coroner’s letter calling for improvements after the suicide of a 22-year-old woman who made seven attempts on her life in two years.
Kerry Hunter was known to the Norfolk and Suffolk Foundation Trust (NSFT) but was discharged from hospital after she felt unable to access the therapy she wanted.
Dialetical Behavioural Therapy (DBT) was available by self-referral in Suffolk - but Miss Hunter’s borderline personality disorder (BPD) made her unlikely to engage with services.
Recording a conclusion of suicide at the two-day inquest in Ipswich, Mr Nigel Parsley said: “This is one of those cases I call a ‘lost chance’ case.
“We will never know if the therapy Kerry wanted would have worked but it is absolutely understandable her family wished she had access to it.”
The letter Mr Parsley will write, a Prevent Future Deaths report, will be the fourth one the NSFT has received in six months.
Now the NSFT, which was rated ‘inadequate’ for a third time in four years in September 2018, is reviewing procedures in the hope the therapy will be more widely available to patients in Suffolk.
NSFT medical director Dr Bohdan Solomka said: “I was so sorry to hear about Kerry’s tragic death and would like to offer my sincerest condolences to her family and friends.
“DBT isn’t offered in NSFT to the level we would wish to offer people with BPD and we have been working with our commissioning partners to address this.”
In a letter submitted to the court, her father, Adam Hunter, said his “worst nightmares were realised” when he found his daughter at her home in Vernon Street, Ipswich, on April 9, 2016, having taken an overdose of prescribed medication.
A note close to the body confirmed her intention to end her life. She died on May 1, 2016.
Mr Parsley heard that despite Miss Hunter’s suicide attempts, one as recently as nine days before she was found, the NSFT deemed her mentally capable of refusing support.
A care plan was devised for Miss Hunter but was not enacted when she declined help, stating therapies she was being offered felt like “more of the same”.
In the days before her fatal overdose Miss Hunter also collected two months of her prescribed medication, a potentially lethal dose.
No alarm was raised because it was collected after two appointments, one with a GP and another through an out-of-hours service which did not have access to her medical records.
What has been happening at the trust?
The trust has received at least three other PFD reports regarding the deaths of patients in Norfolk and Suffolk since November 2018.
Concerns over record-keeping, communication and a failure to keep proper notes were all cited as problems.
The trust was rated ‘inadequate’ for a third time in four years in September 2018 by the Care Quality Commission.
It found improvements had not gone far enough since the trust’s inspection in 2017 and the ‘inadequate’ rating would remain in place.
Speaking in March, Beccy Hopfensperger, Suffolk council cabinet member for adult care, said: “While evidence suggests some early progress, the overall quality and safety provided by NSFT are inadequate, and this council expects further rapid, demonstrable improvements.
“The people of Suffolk deserve to receive good quality mental health services.”
What is a Prevention of Future Deaths (PFD) report?
A PFD is a report sent to a body advising of changes that need to be made to protect future individuals that will use a particular public service.
According to the Courts and Tribunals Judiciary, the Coroners and Justice Act 2009, provides coroners with the duty to make reports to a person, organisation, local authority or government department or agency where the coroner believes that action should be taken to prevent future deaths.
All reports and responses must be sent to the chief coroner.