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Daily Mail Online
By Emma Glanfield for Mail Online
- Pregnant Joanne Norris walked in front of speeding train at Witham, Essex
- 28-year-old and her unborn baby were killed in incident in March last year
- Inquest heard how Mrs Norris had suffered severe anxiety since age of 17
- She took medication to manage anxiety but stopped when she fell pregnant
- Later put back on low dosage by GP who ‘failed to warn her of side effects’
- GP said he didn’t warn her as it was low dose and she had taken it before
- Coroner said opportunities were missed to help her in lead up to her death
A pregnant woman killed herself by walking into the path of a train after a doctor failed to warn her about the side-effects of an anti-anxiety drug, an inquest heard.
Joanne Norris, 28, and her unborn baby died after she walked into the path of a speeding train at Witham station, Essex, on March 16 last year.
An inquest at Essex County Coroner’s Court in Chelmsford heard how married Mrs Norris, who already had a three-year-old daughter called Lily, had suffered with anxiety since the age of 17.
Coroner Michelle Brown said opportunities to help her were missed in the run-up to her death.
The inquest heard how minutes before her death, Mrs Norris sent a text message to her husband Jeff which said: ‘I love you and Lily with all my heart, it’s not your fault I’m like this, I can’t cope anymore, I’m sorry.’
The hearing was told that the teaching assistant had a long-term prescription for anti-anxiety drug Venlafaxine to help manage her symptoms but stopped taking the drug on doctors’ advice when she fell pregnant with her second child.
However, she was prescribed Diazepam after complaining of constant morning sickness and was put back on a low-dosage of Venlafaxine in February last year after telling her GP, Dr Adekunle Olowu, that she was ‘unable to cope’.
The inquest heard that Dr Olowu failed to warn her of the possible side-effects of the anti-depressant.
During the hearing, Norris family counsel Vanessa Marshall grilled Dr Owolu about the decision to prescribe Venlafaxine again.
She asked him: ‘Isn’t it the case that in the early stages of taking Venlafaxine it can cause an increased risk of self-harm or suicidal thoughts?
‘That is an established side-effect of the medication in some cases.
‘It was irrelevant that she had taken it over the years. Each period of taking it is different.’
Dr Olowu said he did not consider there to be a risk due to the reduced amount prescribed, as well as Mrs Norris’ previous experience taking the medication, but admitted he did not warn her of the increased risk.
The inquest also heard how on the day of her death Mrs Norris phoned a mental health crisis team twice and informed them that she was having thoughts about jumping in front of a train.
A nurse arranged a visit to her house later that day but when she arrived four hours later Mrs Norris had already died.
The coroner returned a verdict of suicide but said opportunities to help Mrs Norris had been missed by medical professionals.
She said: ‘Opportunities have been missed in respect of the initial referral to the hospital from the GPs’ practice and the lack of adequate recording in the GPs’ notes meant the evidence was insufficient to ascertain whether she stopped taking the drugs of her own accord or because she was advised to do so.
‘There is also insufficient evidence to show whether restarting the Venlafaxine contributed to her death, or whether the Diazepam was prescribed for sickness or anxiety.
‘However these were clinical decisions made by medical professionals and outside the remit of this inquest.’
The Norris family’s solicitors, Thompson Smith and Puxon, said an investigation into her death by the North Essex Partnership NHS Foundation Trust’s mental health service had highlighted ‘various areas of her care that were of concern’.
It said Mrs Norris was left to seek help herself instead of being referred to experts by professionals.
A similar probe by Colchester General Hospital found care may not have been provided to a standard which may have averted her death.
Solicitor Naomi Eady, who represented Mr Norris at the inquest, said: ‘It is of great concern to Joanne’s family both investigating trusts are critical of the care she received on a number of different levels.’
The law firm added: ‘Based on the evidence presented at the inquest the family will be pursuing a claim.’
The inquest also heard how Mrs Norris’ GP surgery, East Lynne Medical Centre in Clacton-on-Sea, had since changed its procedures to ensure that all expectant mothers are reviewed for mental health problems.
The surgery is also in the process of making improvements to the way it shares information with other health services, the hearing was told.
Colchester Hospital University NHS Foundation Trust has also installed a new computer system which lets GPs access patient records in a bid to reduce communication problems.