Jessica de Souza: Prevention of Future Deaths Report
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Date of report: 16/07/2024
Ref: 2024-0407
Deceased name: Jessica de Souza
Coroner name: Caroline Topping
Coroner Area: Surrey
Category: Suicide (from 2015) | Mental Health related deaths
This report is being sent to: National Institute for Health and Clinical Practice | Royal Pharmaceutical Society | BMJ Group
| REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: 1. [REDACTED], Chief Executive of the National Institute for Health and Clinical Practice 2. [REDACTED], Chief Executive Officer of the Royal Pharmaceutical Society 3. [REDACTED], Chief Executive Officer of the BMJ Group | |
| CORONER I am Caroline Topping assistant coroner, for the coroner area of Surrey. | |
| CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| INVESTIGATION and INQUEST Following an inquest opened on the 14th February 2023 The inquest was concluded on the 16th April 2024. The cause of death was: 1a.) Suspension The conclusion was Suicide. | |
| CIRCUMSTANCES OF THE DEATH Jessica de Souza was diagnosed with bipolar disorder. She suffered an acute manic episode in the summer of 2022. She was detained under section and prescribed aripiprazole. Her condition stabilised. She was discharged to the Home Treatment Team on the 10th November 2022. On the 1st December 2022 her care was transferred to the Community Mental Health Team. She was offered an appointment to see her community psychiatrist on the 19th December 2022 but the appointment letter arrived after that date. The appointment was rescheduled for the 16th January 2023. She suffered a family bereavement on the 16th January 2023 and rang cancelling the appointment. She was spoken to by the psychiatrist and offered a further appointment on the 30th January 2023 when she rang saying she wasn’t feeling well following her bereavement. She was not seen face to face for an assessment by either her community psychiatrist or her care coordinator. Support was not put in place by the community team following the bereavement. Her family were not given information about signs of relapse. Her prescribed medication, aripiprazole, was not effective to prevent her developing a depressive episode. She developed depression and took her own life by hanging herself at her home at [REDACTED] on the 1st February 2023. | |
| CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: i. The treating psychiatrists gave evidence that, following the acute manic episode, Jessica was prescribed aripiprazole as a maintenance prophylactic drug to control both polarities of bipolar disorder. ii. The clinicians relied on the BNF and the BMJ Best Practice Bipolar Disorder in Adults to support their decision to prescribe aripiprazole as prophylaxis for both polarities as a monotherapy. iii. Nice Guidance on Bipolar Disorder [CG185] suggests aripiprazole may be considered as a maintenance treatment to prevent relapse in bipolar disorder. iv. The BMJ refers to aripiprazole being used as a monotherapy to treat bipolar disorder, though does advise that it is more effective in preventing mania than depression. v. The court appointed psychiatric expert gave evidence that aripiprazole is not effective as a prophylaxis in relation to the depressive polarity in bipolar and that as a result Jessica was not protected from a depressive relapse. vi. The expert considered that the guidance relied on may have been misleading for the clinicians. | |
| ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action. | |
| YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 10th September 2024. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | |
| COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Miss de Souza’s Family Surrey and Borders Partnership Cygnet Hospital, Woking I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response. | |
| Caroline Topping, 16th July 2024 |