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Coroner criticises GPs for not following NICE guidance after suicide of patient

The University of Bristol has defended its GP services after criticism from a coroner that it did not follow NICE guidance, following the suicide of a patient.

The university said it and its student health services worked ‘diligently’ to help a student, including securing an emergency appointment with a GP within its student health services who was able to refer her onto specialist mental health professionals.

The coroner for the case criticised the GP services at the university for not following NICE guidance which says patients prescribed with antidepressants should have a follow-up appointment within seven days.

GPs have previously called NICE depression guidance 'not-fit-for-purpose' after raising concerns about 'flawed' methodology and out-of-date evidence used to create the recommendations.  

Natasha Abrahart, a student at the University of Bristol, died by suicide in April 2018, while ‘under the care’ of the local NHS trust's mental health team and the university's GP practice, according to the coroner’s report.

The senior coroner for Avon, Maria Voisin, criticised the healthcare team who treated Ms Abrahart because they had ‘not provided a timely and detailed management plan following a number of assessments by them’.

But, in a Preventing Future Deaths report sent to health secretary Matt Hancock and the GP practice, Ms Voisin said there was a risk the same events could happen again unless the GP practice took action - and called for the practice to put preventative measures in place.

The report said: ‘That management plan should have been in place by the end of March 2018 and by the time Natasha was on her Easter holiday, which would have instilled hope and managed her risk.’

‘In my opinion, there is a risk that future deaths will occur unless action is taken.’

Ms Voisin cited NICE guidelines, under section 1.5.2.7, which state that a person who has depression and is started on antidepressants and considered an increased suicide risk – or is younger than 30 years – should ‘normally be seen after one week and frequently thereafter’ until the risk is ‘no longer considered clinically important’.

Ms Voisin said: ‘In this case, sertraline was prescribed but the NICE guideline was not followed by the mental health trust or the GP practice.’

However, the University of Bristol's deputy vice-chancellor, Professor Judith Squires, said the coroner found 'no fault with the university'. 

Professor Squires said: 'The school’s student administration manager spoke and met with Natasha on many occasions to offer support and advice, and to help her find appropriate professional support. On one occasion she went to Natasha’s flat and personally took her to the Student Health Service to see a GP for an emergency appointment.

'After a referral from her GP in February 2018 Natasha was under the care of specialist mental health professionals and she continued to receive support and advice from staff in the School of Physics.' 

Julie Kerry, director of nursing at Avon and Wiltshire Mental Health Partnership NHS Trust, said: ‘We fully accept the findings of the coroner and recognise that we did not act in accordance to best practice in all of the care provided to Natasha.

‘I want to assure Dr and Mrs Abrahart that we are an organisation that wishes to change things for the better to improve our services for our patients.’

NICE is due to publish new guidelines on antidepressants in February 2020. The guidance was initially expected in January 2018, however it was redrafted due to concerns over its evidence base.

Readers' comments (40)

  • Its a very sad case, but unfortunately there is no cast iron method of preventing suicide. There is no guarantee that having seen her after 7 days would have prevented her death. There is a reality gap between what is a 'guideline' and what is actually achievable in a finite resource system. By seeing some people frequently we deny others access..... what I love about the legal profession is that they dont have to worry about such practical difficulties, they can just sit in their ivory towers and criticise the one event without looking at the potential ramifications elsewhere of a different course of action..... its another good reason not to come back....too many guidelines to follow- has anyone actually sat down to investigate how fully applying all the guidelines would impact care and how many fewer patients we would be able to see? How much time would it take to read every guideline applicable to every patient? And how much time would need to be spent reading the updated guidelines every year? Its impossible to be a 'perfect' GP these days..... the criticism continues......

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  • I'm a psychiatry trainee and can tell you for a fact people started on anti-depressants are definitely not followed up within one week.

    So please Ms Coroner person you are welcome to take the entire mental health services of the UK to court

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  • The problem in this country is that when a bad thing happens the authorities often feel duty bound to blame. That blame is often levelled at the GP.

    Reality is often much more complex.

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  • Coroners often feel the need to justify their existence and are quite trigger happy in laying blame on individuals when they see a negative outcome. This sounds like not a very clear cut case and there is only so much a stretched GP service and NHS can do at the end of the day. You can’t save everybody

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  • Reality is so different from ideal world situation, in a service like ours where urgent mental health cases aren’t seen for weeks by secondary care despite Gp concerns it seems unfair to lambast a poorly resources service for failing to meet unrealistic expectations imposed by nice,
    Toxic no win situation for the Gp and the patient, under resource the service and then blame it when things go wrong, guidelines are what they are, just guidelines and not rigid parameters for care

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  • Tell me why anybody wants to be a GP? Under resourced but with toxic guidelines that are impossible to meet and provide service to all.
    When we see 40 to 50 patients in 11 -12 hour days and still criticized for not doing enough, then it is truly time to rethink the GP profession as a vocation and the open ended Contract as a millstone. Each one of is a Dr Bawa Garba waiting in the wings with manslaughter convictions not far away [ as in her case covering upto 4 other doctors, and it was a Coroner that said care was inadequate].
    Be a GP at your extreme peril to follow impossible guidelines in the real world.

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  • The only practical way to minimize suicide is to initiate constant watch for high risk patients in the community as we do here in prison if the Government is willing to fund it.
    Even with constant watch those determined to taking their own still find a way of doing it.
    So please stop passing all the blame to the Gps who are stretched and under resourced.

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  • The usual blame the GP. 1 week is too short for antidepressants to work. Where are the resources to do this or to watch them 24/7. Unrealistic and impractical. Needs a reality check. The NICE guidance is only a guidance but is highly unhelpful to say the least. The university is quick to pass the bug and nobody is brave enough to say they have tried to help and it is a free world and sometimes people do sadly choose to end it.

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  • With comments like these from the coroner, watch out for your pensions previously paid if one is charged with Gross Negligence Manslaughter when someone kill themselves and you get blamed. Toxic practice in the UK.

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