Clinical & Medical Negligence Newsletter - Attwaters Jameson Hill - Spring 2018

06 | Spring 2018 Medical Negligence Newsletter How failings in mental healthcare provision were found to have ‘significantly contributed’ to the death of a young mother At an inquest held at Norfolk Coroner’s Court in Norwich on 17 April, the jury heard evidence concerning the events leading up to the death of a 36-year-old mother who had a long-running history of mental illness. Katherine Rought-Rought lived in Norwich with her partner and their four-year-old son. On 1 June 2016, her partner found Katherine in the bathroom of their home with a ligature around her neck. She was unresponsive and not breathing. Earlier that day, she had been discharged from the care of the Norfolk and Suffolk NHS Foundation Trust’s Crisis Resolution and Home Treatment Team. Neither her partner nor her family were informed of her discharge, despite her 15-year mental health history, recent low state of mind and suicide attempts in the last two months. At the inquest, the jury were asked to consider various aspects of Katherine’s care: „ „ The apparent poor communication between care teams „ „ The lack of a proper crisis plan „ „ The failure to implement an overarching treatment strategy. The family also had concerns that electroconvulsive therapy (ECT) hadn’t been deployed appropriately, medication had been withdrawn too rapidly despite Katherine’s health clearly declining, and child protection issues weren’t properly attended to. The jury findings – a catalogue of avoidable mistakes The court found that Katherine hadn’t received appropriate care, and this had undoubtedly had a bearing on her decision to end her life. Their findings highlighted: „ „ Her care plan was inadequate both in scope and implementation „ „ Despite concerns expressed by her consultant psychiatrists, her medication had been excessive and inappropriate „ „ The ECT programme had contributed to the deterioration in Katherine’s mental health, no other alternatives were actively pursued Failings in mental healthcare