Source · Prevention of Future Deaths
Karen O’Brien
The mental health service (SEPT) made clinical determinations without adequate inquiry or face-to-face assessment, overriding a GP's referral. The coroner questioned the rigid application of NICE guidelines.
Date
15 Jul 2015
56-day deadline
9 Sep 2015 est.
Responses identified
0 of 2
Coroner's concerns
The mental health service (SEPT) made clinical determinations without adequate inquiry or face-to-face assessment, overriding a GP's referral. The coroner questioned the rigid application of NICE guidelines.
View full coroner's concerns
It is difficult to understand how there can be a clinical determination by SEPT without more inquiry and, preferably, some face-to-face assessment of the patient by a mental health professional.
The NICE guidance is stated to be a recommendation. It must therefore be presumed not to be applied slavishly without careful assessment. The patient’s GP had asked for her to be seen. On what basis did SEPT decide to override the GP’s request?
If the NICE Guideline has been accurately reported in SEPT’s letter to the GP, I respectfully invite NICE to reconsider the guideline.
The NICE guidance is stated to be a recommendation. It must therefore be presumed not to be applied slavishly without careful assessment. The patient’s GP had asked for her to be seen. On what basis did SEPT decide to override the GP’s request?
If the NICE Guideline has been accurately reported in SEPT’s letter to the GP, I respectfully invite NICE to reconsider the guideline.
Report sections
Investigation and inquest
On 21st April 2015 we commenced an investigation into the death of Karen O’Brien born 27th April 1968. The investigation concluded at the end of the inquest on 13th July 2015. The conclusion of the inquest was that Karen O’Brien killed herself. The medical cause of death was Multiple Injuries.
Circumstances of the death
Karen O’Brien suffered from chronic pain and depression. A general practitioner (GP) from London Road Surgery had treated her with sertraline and with paroxetine as well as with pain-killing medication. On 4 November 2014 he referred her to the mental Health Crisis Team because of depression and anxiety with somatization and because she admitted to self-harm thoughts. She was also a carer for her father. The GP asked if the Mental Health Crisis Team could see her.
On 10 November a community mental health nurse from the First
Response Team of South Essex Partnership University NHS Foundation Trust (SEPT NHS) replied by letter to the GP that “based on the information received, we have clinically determined a mental health face to face assessment is not required at this stage”, stating that NICE Guidelines recommended that patients are offered two different types of anti-depressants before being referred to secondary mental health services. (Emphasis added)
On 18th March 2015 the patient registered with Robert Frew Medical Partners and was referred to hospital on 24th March for assessment of a breast lump. On 21st April 2014 Karen O’Brien jumped into the path of an underground train at Liverpool Street station.
On 10 November a community mental health nurse from the First
Response Team of South Essex Partnership University NHS Foundation Trust (SEPT NHS) replied by letter to the GP that “based on the information received, we have clinically determined a mental health face to face assessment is not required at this stage”, stating that NICE Guidelines recommended that patients are offered two different types of anti-depressants before being referred to secondary mental health services. (Emphasis added)
On 18th March 2015 the patient registered with Robert Frew Medical Partners and was referred to hospital on 24th March for assessment of a breast lump. On 21st April 2014 Karen O’Brien jumped into the path of an underground train at Liverpool Street station.
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Report details
- Date of report
- 15 July 2015
- Coroner
- Roy Palmer
- Coroner area
- London (City)
Responses identified
Responses identified
0 of 2
2 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 9 Sep 2015 (estimated).
Sent to
- First Response Team, South Essex Partnership University NHS Foundation Trust
- NICE