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previously called NICE depression guidance 'not-fit-for-purpose' after raising concerns about 'flawed' methodology and out-of-date evidence used to create the recommendations.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

  • a) I know several patients who have committed suicide or severely harmed themselves within 24 hours of a 'low-risk' assessment by mental health professionals, so we obviously cannot get it right always.
    b) if the GP practice had referred to specialist services, then the follow-up would be with specialist services unless referred back or discharged WITH FULL INFORMATION to GP, so the GP practice here is NOT to blame, the secondary care is, and such services generically around the country are NOT following NICE guidelines, when GPs most likely ARE.
    It is important to point out that GPs do NOT need to take action to correct secondary care failures, the Coroner should address her comments ot the failing service directly, and their Medical Director.

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  • I am sorry for the poor student.
    This sad case demonstrates how completely useless NICE guidelines. Predicting suicide is always very difficult as it is not always obvious, or things take a turn foe the worse with no clear warning obviating the ability to intervene

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  • The really stupid thing is the poor GP is now probably suicidal.
    If NICE Guidelines are going to be quoted then the should be followed to the letter. Explain to the patient that they need follow up in a week and if the GP service is too busy to accommodate then they should attend ED and seek review with the crisis team.

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  • Bob Hodges

    SSRIs don't work that quick (i.e. in a week) if they work at all (as a general rule).

    If a GP is looking to practice defensively in the future, they will simply refer EVERYTHING URGENTLY to mental health (who are already swamped) and NOT prescribe SSRIs so they can't be blamed if the patient doesn't present for their arranged follow up after a week. On the whole this will be bad for patients.

    It very strange that a Coroner doesn't feel able to see the utterly subjective nature of the 'follow up at 7 days' bit of the guidance (its a finger in the air at best) and seems to coming from the standpoint that most suicides are preventable (which of course they are not).

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  • Coroners- such a worthy and ancient race.
    I've dealt with a few - they often attempt to marshall detailed medical knowledge in a genuine attempt to provide a learned summary... and fail. They have no context, no framing and no experience. Very worrying that NICE guidelines are now being held up as the best of all possible practice and the precedent is established in court. But hold on - surely a better guideline could have been recommended in court - how about follow up every 36 hours for the first 3 months?

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  • The NICE guidelines are guidelines not a must follow at all costs. You use clinical judgement about when and how to apply. That’s why doctors get paid more than nurses.
    Suicide is very hard to predict and what coroners fail to understand is that risk is fluid. A risk assessment at point A may be markedly out of date an hour later if circumstances suddenly change.
    That said, it is well recognised that in some young people, SSRIs can increase suicidality within a few days of using due to agitation and increase in short term anxiety and in very depressed people the suicide risk often increases as their motor function improves before suicidal ideas lift thus they are more able to act on ideas.
    However, the 1 week guidance is wholly arbitrary. Best to ensure the patient knows about the increase in short term agitation/ anxiety and to come back sooner if this happens.
    Not treating overall is more dangerous.
    The problem is that GPs are left to manage what should be secondary care stuff without training.

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  • Vinci Ho

    You see
    That is exactly the argument we have against NICE all these times , not being self-conscious as far as the reality is concerned. All these academics sitting up at the top of the ivory tower have failed to see the reality that the court and judges would always go along with NICE guidelines as the only reference for drawing legal conclusion. Even if the judges are not immediately conscious , the prosecutors and barristers will dig out the NICE guidelines in cases like this one . NICE always say the guidelines are for guiding the clinicians who can still use their own discretions but sorry , come down to earth and recognise what kind if predicament GP can be thrown into.

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  • And they wonder why there is a shortage of GPs

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  • NICE guidelines should state that they can only be considered as strict protocols if being applied in a properly funded health care system.
    I've been saying this for ages. Come on ex GP Dr Haslam- give us your view.

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  • One of the defining characteristics of 21st Century UK medicine is the gulf between guideline and reality on the ground. In social care and many other public services as well. Those with nice, well defined jobs are protected and ignorant of it.

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