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previously called NICE depression guidance 'not-fit-for-purpose' after raising concerns about 'flawed' methodology and out-of-date evidence used to create the recommendations.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

  • Just Your Average Joe

    The story is tragic, as are all unexpected deaths from self harm.

    In an ideal coroner world - All suicidal patients should be admitted to a state of the art inpatient psychiatry service with immediate access to psychological therapies.

    The realities of provision of services in a tight budget means, even those inpatients with lots of support can self harm and successfully kill themselves while in psychiatric units under close observation.

    Checking in 7 days is fine, but a truly suicidal person may take their life at any time.

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  • Why is it that such out of touch idiots get so high up the greasy pole?
    If a coroner cannot understand that a 'guideline' is exactly that then surely he/she is not fit to practice themselves?

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  • "If a coroner cannot understand that a 'guideline' is exactly that then surely he/she is not fit to practice themselves?"

    If the GMC cannot understand that Dr BG had no reason to be convicted or have her licence revoked then surely they are not fit to practice themselves?

    The NHS is an utter joke of leaders who think the customer is always right.

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  • Throughout the health service, commissioners and providers have to balance the guidelines (including nice guidelines) against the resources available. For example fertility guidelines are routinely not followed. And even in mental health the journey to face to face cbt is not in line with guidance (in my area and I suspect every area).

    So why should this provider be treated differently. Is it just because GPs are easy targets?

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  • This is why NICE has long passed it’s sell by date. These so-called guidelines have become an out of control monster that needs shutting down as a matter of urgency. They aren’t fit for purpose implying a level of simplicity in what are more often than not extremely complex human situations. We’d be far better off reinvesting their budget on routine NHS care and passing financial rationing back to parliament where it belongs.

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  • Wouldn’t it be more reasonable not to blame anyone. This patient’s death is tragic. She was seen by a doctors, referred to the local mental health team but still died tragically. Her death is sad- but with the resources available - care seems to have been adequate. When coroners start to quote guides on what should happen to what should happen - then there is a problem.

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  • Una Coales. Retired NHS GP.

    Really sorry for Dr and Mrs Abrahart. My sincerest condolences. I can't imagine the unbearable pain of losing a young adult child. When I read of student suicides at university, the first thing I ask is were they put on an SSRI antidepressant or even worse without the knowledge of their parents? Suicidality increases in young adults under 25 put on SSRIs which is why they require close monitoring. https://www.nhs.uk/news/mental-health/antidepressants-and-suicide-risk/#

    In my opinion, no one under 25 should be put on an SSRI. Back in my days at university, no one had heard of SSRI antidepressants. Universities offered student counselling. And people dealt with stress, anxiety and depression by talking to friends, joining clubs for everything from fencing to drama, etc.

    My daughters have all experienced the high level of stress at university these days with coursework and exams and some universities now survey their students regularly for stress, insomnia, depression etc. In fact unsurprisingly, findings are often that most students have experienced mental health issues while cramming for exams.

    I hope we as a society can go back to a time when we were able to cope with stress, anxiety and depression without the help of Big Pharma. I for one am living proof that even after being kidnapped, beaten, raped, robbed and left half clothed in 2 feet of snow by a serial rapist in Baltimore during my time there as a university student, I was able to recover without SSRIs and instead prayed to God for help and He brought a Catholic friend into my life who was like a big brother to me until I graduated. It made me wonder as a Protestant why there was such bias against Catholics from Protestants.

    I also survived 2 vexatious GMC referrals and the long months to get cleared not by taking SSRIs but by relying on many, many friends and getting counselling.

    If anyone can tell you about suicide activation side effect of an SSRI, I can having experienced this in 2004 and would not recommend this on my worst enemy. For those it works on that is fine but we all have different body chemistry and genes, so what works for some, may not for others.

    Now in my retirement, I am refusing statins.

    If a student reads this, please know that an antidepressant is not a happy pill but can have many side effects, one of which is suicide activation or increases suicidality in someone who has never had suicidal thoughts before, especially if you are under 25 or a small adult.

    To the GP who prescribed SSRIs to a student, please read up on suicide activation on SSRIs as it can be as high as 33%.

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  • Una Coales. Retired NHS GP.

    P.S. She suffered from stage fright/performance anxiety! Why was she put on an SSRI? Why not a beta blocker, bach's rescue spray, counselling, speech or drama class, university making allowances for her, etc. She was 1 of 12 student suicides since September 2016 at Bristol university! Shocking! How many were started on ssri's as if they were harmless happy pills?

    https://www.google.com/amp/s/amp.theguardian.com/education/2019/may/13/natasha-abrahart-inquest-no-support-for-vulnerable-student

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  • accessdata.fda.gov
    "There has been a long standing concern, however, that antidepressants may have a role in inducing worsening of depression and the emergence of suicidality in certain patients during the early phases of treatment".

    This adverse drug reaction (ADR) has been reported in healthy volunteers. (SSRI).

    accessdata.fda.gov
    "All patients being treated with antidepressants FOR ANY INDICATION should be monitored appropriately and observed for clinical worsening, suicidality, and unusual changes in behaviour, especially during the initial few months of a course of drug therapy or at times of DOSE CHANGES, either increases or decreases".

    (My emphasis - the same should apply to any change of antidepressant drug).

    This recommended observation is presumably required for the early identification of AKATHISIA and/or BEHAVIOURAL TOXICITY.

    How can any G.P. "monitor" this?

    Parents, partners, flat sharers, loved ones are those who might achieve this safeguard, but they must be informed, and understand the reasons for doing so.

    (Refer to: The Behavioural Toxicity of Psychotropic Drugs. Di Mascio 1968. Perl et al 1980.
    Fava G.A et al - Editorial 2019).

    Behavioural Toxicities, and Akathisia in patients given SSRIs for non-depressive conditions may have fatal consequences.

    Rather than criticise prescribers, might not coroners, prescribers, parents and loved ones work collaboratively?

    Together, they would have the opportunity to review, and to document, detailed prescription events and relate the timing of drug and dose changes to the onset of both Behavioural Toxicities and/or Akathisia.

    This would clarify the controversial, but evidence based,
    "taking-of-life-by-self" via adverse drug reactions.
    A loss of life which, unless specifically investigated, may be vulnerable to inappropriate recording as "Suicide".

    A tragic, preventable loss of life.

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  • Amazing how the topic of suicide and antidepressants gets people so emotional and extreme in views.
    The number needed to treat for antidepressants in depression or properly diagnosed anxiety is so much higher than for statins or other ‘medical’ drugs.
    Why do people view the brain as somehow different to another organ?
    Also , if NICE guidelines became protocols then all doctors would be out of a job and patients would be mass produced objects not individuals.

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