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You can find the current article at its original source at https://www.theguardian.com/society/2019/may/23/coroner-writes-to-health-secretary-over-mental-health-care
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| Coroner writes to health secretary over mental health care | Coroner writes to health secretary over mental health care |
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| A coroner has highlighted concerns over the care given to a young woman with severe obsessive compulsive disorder who killed herself while on leave from a mental health hospital. | A coroner has highlighted concerns over the care given to a young woman with severe obsessive compulsive disorder who killed herself while on leave from a mental health hospital. |
| An inquest jury in Winchester concluded that Sasha Forster, a 20-year-old student, killed herself by ingesting medication that she knew was highly toxic when taken in large amounts. | An inquest jury in Winchester concluded that Sasha Forster, a 20-year-old student, killed herself by ingesting medication that she knew was highly toxic when taken in large amounts. |
| The coroner, David Reid, said he would write to the health secretary, Matt Hancock, over how Forster was able to obtain medication from a private GPs’ practice in London when her own NHS doctors had stopped prescribing it amid fears she would harm herself. | The coroner, David Reid, said he would write to the health secretary, Matt Hancock, over how Forster was able to obtain medication from a private GPs’ practice in London when her own NHS doctors had stopped prescribing it amid fears she would harm herself. |
| Sasha Forster: a 'lovely, clever' woman let down by a litany of failures | |
| Reid said he would also write to Hancock about evidence that the hospital treating Forster after she was sectioned following an earlier apparent suicide attempt did not have enough staff to bring her back to hospital when she absconded. | Reid said he would also write to Hancock about evidence that the hospital treating Forster after she was sectioned following an earlier apparent suicide attempt did not have enough staff to bring her back to hospital when she absconded. |
| Sasha’s family believe that the young woman was badly let down. In a statement released through the charity INQUEST they said: “Sasha had so much to live for and she tried so desperately hard to get well. We feel that this inquest has shown the flaws and inconsistencies in the system that let her down. | Sasha’s family believe that the young woman was badly let down. In a statement released through the charity INQUEST they said: “Sasha had so much to live for and she tried so desperately hard to get well. We feel that this inquest has shown the flaws and inconsistencies in the system that let her down. |
| “On the day of Sasha’s death there was no clear crisis plan in place for staff to follow, and a psychiatric team refused to see Sasha.” They added: “Sasha was often dismissed by some staff as they labelled her as attention seeking. We hope that by shining a light on these issues, actions will be taken to prevent other young adults and their families having the same experience.” | “On the day of Sasha’s death there was no clear crisis plan in place for staff to follow, and a psychiatric team refused to see Sasha.” They added: “Sasha was often dismissed by some staff as they labelled her as attention seeking. We hope that by shining a light on these issues, actions will be taken to prevent other young adults and their families having the same experience.” |
| During a four-week inquest described as “harrowing” by the coroner, the jury heard how Forster’s OCD became so intense that she had to complete hours of rituals before she could even get out of bed. | During a four-week inquest described as “harrowing” by the coroner, the jury heard how Forster’s OCD became so intense that she had to complete hours of rituals before she could even get out of bed. |
| She believed there was evil inside her and if she did not carry out the rituals, harm would come to herself and her family. | She believed there was evil inside her and if she did not carry out the rituals, harm would come to herself and her family. |
| The jury was told that after doctors had stopped prescribing a certain medication because they were worried she would misuse it, she twice visited a private GP service miles away from her home. Two doctors gave her a total of six weeks’ worth of the medication though they had no access to her notes. It has not been possible to establish if the medication she was prescribed by the private GPs was the actual one she used to kill herself. | The jury was told that after doctors had stopped prescribing a certain medication because they were worried she would misuse it, she twice visited a private GP service miles away from her home. Two doctors gave her a total of six weeks’ worth of the medication though they had no access to her notes. It has not been possible to establish if the medication she was prescribed by the private GPs was the actual one she used to kill herself. |
| On 10 January 2017 Sasha almost died following an overdose. She was detained under the Mental Health Act and became a patient at Farnham Road hospital in Guildford, Surrey, a specialist mental health facility run by Surrey and Borders Partnership NHS foundation trust. | On 10 January 2017 Sasha almost died following an overdose. She was detained under the Mental Health Act and became a patient at Farnham Road hospital in Guildford, Surrey, a specialist mental health facility run by Surrey and Borders Partnership NHS foundation trust. |
| Staff struggled to cope with her and she was allowed home on temporary leave. She began to split her time between home and the hospital. But her family say the overdose damaged her short-term memory. She could remember the concept of her rituals – but not the complicated repetitive actions she felt she had to do to keep her family safe. | Staff struggled to cope with her and she was allowed home on temporary leave. She began to split her time between home and the hospital. But her family say the overdose damaged her short-term memory. She could remember the concept of her rituals – but not the complicated repetitive actions she felt she had to do to keep her family safe. |
| On 31 March 2017 she suffered a serious crisis at home. Her mother, Angela, told the inquest that she tried to take her to see a psychiatric liaison team run by the Surrey and Borders trust at a hospital in Frimley, Surrey, but was turned away because there was confusion over her care plan. | On 31 March 2017 she suffered a serious crisis at home. Her mother, Angela, told the inquest that she tried to take her to see a psychiatric liaison team run by the Surrey and Borders trust at a hospital in Frimley, Surrey, but was turned away because there was confusion over her care plan. |
| She ran away and was found by police but they had no power to confiscate the medication she had on her. The inquest was told shortages meant the Farnham Road hospital did not have enough staff to allow one of them to leave the site and fetch her. Police let her go and she was found dead later that day next to a pond. | She ran away and was found by police but they had no power to confiscate the medication she had on her. The inquest was told shortages meant the Farnham Road hospital did not have enough staff to allow one of them to leave the site and fetch her. Police let her go and she was found dead later that day next to a pond. |
| Catherine Shannon, of Bhatt Murphy Solicitors and Sophy Miles, of Doughty Street Chambers, who acted for the family, said: “Sasha was detained under section 3 of the Mental Health Act at the time of her death; she was at high risk and vulnerable. This inquest has raised important questions about the ability of mental health providers to plan crisis care for those on leave from hospitals and to recall and return them safely when this becomes necessary.” | Catherine Shannon, of Bhatt Murphy Solicitors and Sophy Miles, of Doughty Street Chambers, who acted for the family, said: “Sasha was detained under section 3 of the Mental Health Act at the time of her death; she was at high risk and vulnerable. This inquest has raised important questions about the ability of mental health providers to plan crisis care for those on leave from hospitals and to recall and return them safely when this becomes necessary.” |
| Deborah Coles, director of INQUEST, said: “Deeply concerning evidence was heard during this inquest, which pointed towards gaps and missed opportunities in the way various agencies responded to Sasha’s mental health crises.” | Deborah Coles, director of INQUEST, said: “Deeply concerning evidence was heard during this inquest, which pointed towards gaps and missed opportunities in the way various agencies responded to Sasha’s mental health crises.” |
| Dr Justin Wilson, chief medical officer at Surrey and Borders partnership NHS foundation trust, said after the conclusion that there were inconsistencies in the care provided to Forster. | Dr Justin Wilson, chief medical officer at Surrey and Borders partnership NHS foundation trust, said after the conclusion that there were inconsistencies in the care provided to Forster. |
| Wilson said the trust had already made “several key developments” in areas such as improving partnerships with emergency services colleagues and managing leave. | Wilson said the trust had already made “several key developments” in areas such as improving partnerships with emergency services colleagues and managing leave. |
| In the UK and Ireland, Samaritans can be contacted on 116 123 and the domestic violence helpline is 0808 2000 247. In Australia, the crisis support service Lifeline is 13 11 14 and the national family violence counselling service is 1800 737 732. In the US, the suicide prevention lifeline is 1-800-273-8255 and the domestic violence hotline is 1-800-799-SAFE (7233). Other international helplines can be found at www.befrienders.org | In the UK and Ireland, Samaritans can be contacted on 116 123 and the domestic violence helpline is 0808 2000 247. In Australia, the crisis support service Lifeline is 13 11 14 and the national family violence counselling service is 1800 737 732. In the US, the suicide prevention lifeline is 1-800-273-8255 and the domestic violence hotline is 1-800-799-SAFE (7233). Other international helplines can be found at www.befrienders.org |
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