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previously called NICE depression guidance ‘not-fit-for-purpose’ after raising concerns about ‘flawed’ methodology and out-of-date evidence used to create the recommendations.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


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