Mental health care system failed ‘low-risk’ suicide mother of two — (The Gloucestershire Review)

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The Gloucestershire Review

Thursday, 23 October 2014

THE DISTRAUGHT family of a 39-year-old woman who hanged herself after being assessed as a low suicide risk have lashed out at the mental health treatment the mum-of-two received.

After an inquest into the death of Victoria Phelps of Wilton Road, Gloucester on August 6th, 2012, the mother of the deceased, Gayle Tucker said: “After one of her suicide attempts I begged that my daughter be sectioned so that she could be looked after properly.

“To say someone is at a low risk of suicide when she has made previous attempts is just not on. My daughter has been let down.”
Victoria’s brother Brett Phelps added: “My sister only started having suicide thoughts and making attempts when she was prescribed Fluoxetine. I’ve been doing some research into the drug and reckon that it was a death sentence for my sister.”

Senior Coroner for Gloucestershire Katy Skerrett said: “It is quite clear that from 1992 this lady suffered on-off with anxiety. She was a working lady with two sons and had been taking anti-depressants since 2000.   “In April 2012 things came to a head due to a relationship breakdown and this triggered events in a bad way.”

Victoria took a drug overdose and was admitted to Gloucestershire Royal Hospital. She then waded into a canal and spoke to friends about ending her life, the inquest at Barnwood was told.   Police Constable Karen Raistrick told the inquest: “I attended her home on a previous occasion when she tried to hang herself in the garage and I was on duty when I was again called to the house on August 6th that same year, but this time we found her dead.”

Victoria’s son had handed police a key to the garage and was just prevented in time by a friend from walking in and seeing his mother hanging by a dressing gown cord.   Despite the previous history of anxiety and depression and suicide attempts, which included superficially cutting her wrist, mental health liaison nurse Julie Nicholson assessed her as being at low risk of self-harm “but this increased when alcohol was consumed.”

In a written statement to the inquest the nurse said that the family was asked to look after her medication “to reduce the risk of overdose.”   “The patient did not want to die but told me that she would sometimes drift into a tunnel,” said the nurse. “She seemed flat and worried.”

Ms Skerrett reiterated the deceased’s recent mental health history: depression after an aunt died in 2005, anxiety in 2007 and 2008, panic attacks in 2009 and 2011, overdose and hospital admission in 2012, insomnia after relationship breakdown the same year, depressed and suicidal thoughts in July 2012.

She was referred to psychiatrist Prakash Muthu for a crisis assessment in July 2012 and he gave evidence at the inquest yesterday.   “She told me about the overdose and the episode wading into the canal and also the cut wrists but she clearly regretted her actions, felt scared of what she had done and wanted help,” said the psychiatrist.   “But she told me that she had no more suicidal thoughts and I assessed her as being of low risk of suicide. She maintained good eye contact during my assessment and seemed to be looking to the future.”

Dr Muthu said that he recommended a change in medication and told her that, as part of her risk management, she should contact The Samaritans. But the psychiatrist denied that there was an increased risk of suicide associated with Fluoxetine.

Ms Skerrett concluded that she could not be sure that Victoria intended to take her own life and there was reasonable doubt.   “This may have been a cry for help and I will give a narrative conclusion,” she said.    After retiring for ten minutes the coroner returned to the courtroom and delivered her narrative conclusion: “This 39-year-old lady was suffering from depression and anxiety, triggered by a relationship breakdown in March 2012.   “She made a few suicidal attempts in the weeks preceding her death. However it is unclear whether she had formed a clear intention to die.”

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