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A senior coroner has expressed concern about how a students’ health service prescribed anti-depressants to a deeply stressed 20-year-old who went on to kill herself, the Guardian can reveal.
The Bristol University physics student Natasha Abrahart, who had severe social anxiety, was found hanged at her student flat on the day of an oral test she had been dreading.
The senior coroner for Avon, Maria Voisin, has written to the health secretary, Matt Hancock, saying guidelines from the National Institute for Health and Care Excellence (Nice) were not followed in her case.
On 20 April last year, Abrahart was seen at the university’s students’ health service by a GP who noted she had run out of medication. She was issued with a prescription for anti-depressants but no arrangements were made for a seven-day follow-up as per Nice guidance.
The inquest was told that the “usual practice” of all GPs at the students’ health service was to make follow-up appointments two weeks after prescribing anti-depressants.
At the end of Abrahart’s inquest last week the coroner focused on failings by the Avon and Wiltshire mental health partnership NHS trust (AWP) in its dealings with her. Voisin concluded that neglect by AWP contributed to Abrahart’s death.
In a “preventing future deaths” report, the coroner also flagged up concerns about the lack of a seven-day follow-up.
According to the Nice guidance a person with depression started on anti-depressants who is considered to be an increased suicide risk or is younger than 30 should normally be seen after one week and as frequently thereafter as appropriate.
The coroner said a review of Abrahart’s health could have been carried out by a GP or a member of the mental health team. Voisin said in this case the Nice guidelines were not followed by the GP practice or the mental health team.
As well as writing to the health secretary, Voisin sent her report to the minister for suicide prevention, Jackie Doyle-Price, the students’ health service and AWP.
The coroner wrote: “In my opinion there is a risk that future deaths will occur unless action is taken.”
Abrahart’s family said that if the guidelines had been followed she would have been seen no later than 27 April.
Her parents, Margaret and Robert, said in a statement: “If the students’ health service had followed the guidance then Natasha would have seen a doctor three days before her death.
“We will never know what difference this would have made but at the very least it would have given her an opportunity to have a conversation about how she was feeling with someone who was medically qualified.”
Abrahart was the 10th of 12 students at Bristol University known or suspected to have killed themselves since September 2016.
Gus Silverman, a public law and human rights lawyer at Irwin Mitchell, representing Natasha’s family said: “It is a matter of significant concern that the usual practice of GPs within the University of Bristol’s students’ health service appears to breach the guidance issued by Nice.”
Anita Sharma, of the charity Inquest, which has been supporting the family, said: “What could be of higher priority to a students’ health service than properly monitoring the suicide risk of vulnerable students, particularly after numerous previous self-inflicted deaths at Bristol University?”
The students’ health service offers full NHS GP services to all University of Bristol students who choose to register with it, if they live within the practice area.
A University of Bristol spokesperson said: “The university works in partnership with the NHS to enhance the level of primary health care provided to our students and this is reflected in the university’s ongoing investment into the running of the students’ health service. The SHS has confirmed they have received the prevention of future deaths report to the practice and will respond directly to the coroner.”