Source · Prevention of Future Deaths
John Thorpe
Ref: 2014-0340
Date: 23 Jul 2014
Coroner: Paul Cooper
Area: South Lincolnshire
Responses identified: 0 / 2
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The deceased was inappropriately asked to self-refer to mental health services, and crucial follow-up was absent. Doctors failed to adequately consider the increased suicide risk associated with starting antidepressants in a patient with a history of attempts.
Date
23 Jul 2014
56-day deadline
16 Sep 2014
Responses identified
0 of 2
Coroner's concerns
The deceased was inappropriately asked to self-refer to mental health services, and crucial follow-up was absent. Doctors failed to adequately consider the increased suicide risk associated with starting antidepressants in a patient with a history of attempts.
View full coroner's concerns
_ That the deceased was asked to "self-refer" himself to IAPT rather_than a direct referral being made_on his behalf to an appropriate mental health resource His widow was particularly critical of this at the Inquest; commenting she attempted to fill the form in for him but it wasn't completed and she believed her husband would have responded if a direct referral had been made. appreciate this may be 'standard practice' but the point is surely not in case and Doctors should be encouraged to use their discretion more That no intention to follow him Up, with a definite appointment being given or by telephone contact; is recorded in the clinical records_ Thatl knowledge, elicited at the inquest; that "sometimes when being again 2014, dogs railing tracking days every
A RW Forrest LLM, FRCP, FRCPath GMC Number: 1333523 Her Majesty's Senior Coroner for South Lincolnshire_ anti-depressant is started it can give you more energy" and that Mr Thorpe had history of a previous suicide attempt was apparently not considered together with the advice in the British National Formulary on suicidal behaviour and treatment with anti-depressants, viz; "the use of anti-depressants has been linked with suicidal thoughts and behaviour; children, young adults and patients with a history of suicidal behaviour are particularly at risk, where necessary patients should be monitored for suicidal behaviour, self-harm, or hostility, particularly at the beginning of treatment or if the dose is changed"
A RW Forrest LLM, FRCP, FRCPath GMC Number: 1333523 Her Majesty's Senior Coroner for South Lincolnshire_ anti-depressant is started it can give you more energy" and that Mr Thorpe had history of a previous suicide attempt was apparently not considered together with the advice in the British National Formulary on suicidal behaviour and treatment with anti-depressants, viz; "the use of anti-depressants has been linked with suicidal thoughts and behaviour; children, young adults and patients with a history of suicidal behaviour are particularly at risk, where necessary patients should be monitored for suicidal behaviour, self-harm, or hostility, particularly at the beginning of treatment or if the dose is changed"
Report sections
Investigation and inquest
On 8th April 2014 commenced an investigation into the death of John William THORPE, age 78_ The investigation concluded at the end of the inquest on 19TH June 2014. The conclusion of the inquest was SUICIDE
Circumstances of the death
In February 2014 the deceased consulted Foundation Year 2 trainee doctor at Swineshead Medical Group Practice, for non-specific symptoms including low
A RW Forrest LLM, FRCP, FRCPath GMC Number: 1333523 Her Majesty's Senior Coroner for South Lincolnshire mood. A variety of investigations were initiated, with no significant pathology being elucidated. He again consulted on 12th March 2014 complaining of feeling more tired and with low mood. Feelings of hopelessness and self-harm were elucidated. A PHQ-9 screening test was administered with a score of 16/27 obtained, indicative of moderately severe depression: Mr Thorpe was given a prescription for 20 milligrams of the anti-depressant fluoxetine daily and asked to self-refer himself to "IAPT" (Improving Access to Psychological Therapies) He was given no firm appointment to be seen at the practice, but the plan noted in the clinical records was to see him again in 1 months time On 24th March Mr Thorpe left his home, taking his for a walk: His dogs were found tethered to a adjacent to the Forty Foot Drain, a large drainage dyke, at Swineshead Bridge. Footprints, matching his boots were found down into the dyke and he was found floating in the middle of the dyke The post mortem indicated that the cause of death was drowning and that he had been taking fluoxetine regularly in the before his death as well as diphenhydramine
A RW Forrest LLM, FRCP, FRCPath GMC Number: 1333523 Her Majesty's Senior Coroner for South Lincolnshire mood. A variety of investigations were initiated, with no significant pathology being elucidated. He again consulted on 12th March 2014 complaining of feeling more tired and with low mood. Feelings of hopelessness and self-harm were elucidated. A PHQ-9 screening test was administered with a score of 16/27 obtained, indicative of moderately severe depression: Mr Thorpe was given a prescription for 20 milligrams of the anti-depressant fluoxetine daily and asked to self-refer himself to "IAPT" (Improving Access to Psychological Therapies) He was given no firm appointment to be seen at the practice, but the plan noted in the clinical records was to see him again in 1 months time On 24th March Mr Thorpe left his home, taking his for a walk: His dogs were found tethered to a adjacent to the Forty Foot Drain, a large drainage dyke, at Swineshead Bridge. Footprints, matching his boots were found down into the dyke and he was found floating in the middle of the dyke The post mortem indicated that the cause of death was drowning and that he had been taking fluoxetine regularly in the before his death as well as diphenhydramine
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you andlor your organisation have the power to take such action:
Copies sent to
RW Forrest LLM, FRCP, FRCPath GMC Number: 1333523 Her Majesty's Senior Coroner for South Lincolnshire 23rd July 2014 PS Cooper HM Assistant Coroner for South Lincolnshire Unit 1, Gilbert Drive, Endeavour Park, Boston PE21 7TQ Tel: 01522 553374 Fax: 01522 516717 Email: HMCoroner_Southlincolnshire@lincolnshire gov.uk
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Report details
- Reference
- 2014-0340
- Date of report
- 23 July 2014
- Coroner
- Paul Cooper
- Coroner area
- South Lincolnshire
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: 16 Sep 2014.
Sent to
- East Midlands Local Education and Training Board
- Lincolnshire East Clinical Commissioning Group