Ref:     2017NICORONER9
Neutral Citation No:  [2017] NICoroner 9

Judgment: approved by the Court for handing down
(subject to editorial corrections)* 

Delivered: 01/12/2017

IN THE CORONERS COURT FOR NORTHERN IRELAND
__________
IN THE MATTER OF
AN INQUEST INTO THE DEATH OF 
SABINA DOLL
________
Before: Coroner Patrick McGurgan

[1]	The Deceased, Sabina Doll, born on the 2nd July 1990, of 18 Coburg Street, Belfast, died on the 27th June 2016.
[2]	The Deceased had been diagnosed with Type 1 diabetes in or around November 2012. In 2013, she was diagnosed with depression and borderline personality disorder trait with psychotic ideas.   She had been referred to mental health services and was on medication for same.
[3]	In her evidence to the Inquest, Mrs Fiona Blythe, Social Worker, stated that the Deceased first came to the attention of mental health services when she was referred to the South Belfast Recovery Team (“SBRT”) by the Mater Hospital on 2nd September 2013. This followed a period of compulsory admission following an attempt to jump of the Foyle Bridge in Londonderry.
[4]	Following a deterioration in her mental health, the Deceased was again admitted to the Mater Hospital under the Mental Health (NI) Order 1986 in January 2014 for further assessment. The Deceased was discharged on 20th March 2014 and Mrs Blythe was allocated as her key worker and Dr Gerry Loughrey as her Community Consultant Psychiatrist.
[5]	Mrs Blythe explained that there were numerous contacts between her and the Deceased between 2013 and 2016 either by home visits or telephone. The Deceased did, on occasions, express low mood, poor motivation and thoughts of life not worth living however, she continually denied any suicidal intent.
[6]	In April 2014, the Deceased was referred to an Occupational Therapist, Mr Neil McCullough but she disengaged with this service.  She was also referred to various voluntary agencies at this time.
[7]	In May 2014, the Deceased, by agreement, was referred  by Mrs Blythe to Mr Hugh Scullion of the Psychology Service and on assessment in October 2014, the Deceased agreed to participate in a 10 week programme to help her deal more positively with her mental illness. The Deceased attended 5 of the sessions.
[8]	The Deceased also disengaged with other services and her reasoning was that she had lost interest and motivation in them.
[9]	The Deceased’s health and intermittent engagement with services were discussed at multi-disciplinary meetings and in April 2015 Dr Loughrey felt that the Deceased’s diagnosis was possibly in keeping with personality disorder rather than psychosis. Throughout this time the Deceased was able to live independently.
[10]	On the 5th October 2015 the Deceased attended a review appointment with Dr Loughrey. On the same date she complained to Mrs Blythe that Dr Loughrey did not understand her difficulties and again on the 19th October, Mrs Blythe noted that she was angry and unhappy with Dr Loughrey.
[11]	On the 29th October Mrs Blythe received a telephone call from Dr Gowdy GP, stating that the Deceased wanted a new Consultant Psychiatrist and that she was buying medication over the internet. 
[12]	At a Multi-Disciplinary Team meeting on the 2nd November 2015, Mrs Blythe discussed with Dr Loughrey the issues which had been raised by the Deceased and by her GP.  Mrs Blythe understood from her discussion that Dr Loughrey was going to address the concerns directly with the GP. 
[13]	On the 9th November 2015 Mrs Blythe spoke with the Deceased about buying the medication but the Deceased was adamant that she was going to continue purchasing it and that she would not be attending Dr Loughrey’s outpatient clinic.
[14]	Mrs Blythe last met with the Deceased on the 8th March 2016 and noted an improvement in her mental health.  The Deceased also reported that she had decided to stop taking the medication she was obtaining over the internet as she was engaging in work with the Self Harm Team.  The Deceased further agreed a referral to another Occupational Therapist at that time.
[15]	Unfortunately, Mrs Blythe went on long term sick leave and therefore had no further dealings with the Deceased.
[16]	Mrs Elaine McAlister, Mrs Blythe’s team leader wrote to the Deceased on the 5th May 2016.
[17]	On the 14th March 2016, Mrs Blythe had referred the Deceased to Ms Jenny Harpur, Occupational Therapist. She was off work from the 14th March until the 25th April 2016. 
[18] 	Ms Harpur attempted to contact the Deceased on the 3rd May 2016 and on the 5th May 2016 by telephone without success. As a result, herself, and Mrs McAlister paid an unannounced visit to the Deceased on the 5th May 2016.
[19] 	There were a number of face to face and telephone contacts between Ms Harpur and the Deceased until the 17th June 2016.  It appeared at this time that the Deceased was engaging with the services being offered.   
 [20]	In his evidence, Dr Gerry Loughrey, Consultant Psychiatrist, stated that he first saw the Deceased on the 2nd June 2014.  He was aware that the Deceased had already been with Mrs Blythe. He identified that the Deceased had flat mood, poor motivation over sleeping and withdrawal.  She described hearing voices and feeling paranoid.  Dr Loughrey suggested no change in her medication at that time.
[21]	Dr Loughrey next met with the Deceased on the 29th August 2014 and in a letter to her GP, Dr Loughrey felt that the Deceased was a borderline personality type. He also noted that her compliance with her antidepressant medication was indifferent.
[22]	The Deceased was seen again by Dr Loughrey on the 31st October 2014 at which time he was aware that she was attending Mr Hugh Scullion, nurse specialist. At this stage Dr Loughrey did not feel that the Deceased had a true paranoid illness. 
[23]	The Deceased did not attend her appointment with Dr Loughrey on the 30th January 2015.
[24] 	The Deceased was seen again on the 24th April 2015. Her compliance with medication was still poor and she was still complaining of hearing voices. At this time Dr Loughrey felt that the Deceased had:
 	“ a full borderline personality disorder, with some depressive symptoms..”
[25]	Dr Loughrey explained to the Deceased that the appropriate treatment would be a combination of medication and psychological therapy. The Deceased did not want to consider psychotherapy at that time. The Deceased continued to be on Duloxetine, Mirtazapine and Quietiapine.
[26]	Dr Loughrey wrote a letter to the Deceased’s GP in May 2015 whereby he recommended an increase in her Quietiapine.
[27]	Dr Loughrey next met with the Deceased on the 3rd August 2015 and he found her to be unchanged. He suggested a further increase in her Quietiapine and took her to task over the use of street diazepam.
[28]	At her next appointment on the 5th October 2015 Dr Loughrey impressed upon the Deceased the necessity for psychological therapy.  Dr Loughrey agreed with the Deceased that her sessions with Mr Scullion were of limited benefit as given Dr Loughrey’s diagnosis, Mr Scullion’s sessions may not be the most appropriate.  
[29]	Dr Loughrey referred the Deceased at this meeting to the Self Harm Team.  I find that this was an appropriate referral. 
[30]	Dr Loughrey accepted that at the Multi-Disciplinary Team Meeting on the 2nd November that he had undertaken to contact the Deceased’s GP regarding the issue of her wanting to change consultants and other issues brought to his attention by Mrs Blythe. 
[31]	Dr Loughrey further accepted that he had forgotten to follow up on his undertaking and at no time did he discuss either with the GP or with another consultant colleague the Deceased’s desire to change consultants. 
[32]	At the time there was no formal note taker present at Multi-Disciplinary Meetings and given his workload this particular issue had slipped his mind.  Further, there were no reviews of minutes from previous meetings at subsequent meetings.
[33]	To avoid a reoccurrence of this type of issue Dr Loughrey instructed those attending Multi-Disciplinary Team Meetings to email his secretary with tasks that he would need to attend to as an aide-memoire. 
[34]	I find the policy of no formal minute taking at these meetings to be unsatisfactory and the evidence suggests that the various Trusts should review this policy moving forward.   
[35]	Given that Dr Loughrey had referred the Deceased to the Self Harm Team I find that Dr Loughrey’s omission in dealing with the transfer issue had no impact on the care of the Deceased.   

[36] 	It appears that the Deceased disengaged with Dr Loughrey as she wanted her medication altered.  Notwithstanding this disengagement, Dr Loughrey’s team continued to have input into the Deceased’s care.
[37] 	The Deceased was invited to attend an information session regarding the Self Harm Team on the 7th March 2016.  The Deceased did attend this session and she completed and returned an opt-in letter on the 14th March 2016.
[38] 	The Deceased then attended for her initial assessment with Dr Carville, trainee Psychiatrist on the 27th May 2016.  At that initial assessment meeting, the Deceased reported feeling an “excitement” at times when taking overdoses or not taking her insulin as she did not know what could happen.  She also indicated that she had not been taking her prescribed medication since January 2016 as she had felt better and that she was engaging with her Occupational Therapist.
[39]	Following a Multi-Disciplinary Team discussion, the Deceased was invited to participate in an eight week Foundation Group to allow her to both engage in a psychological treatment and to allow for a period of assessment. This was to consider if the Deceased would be suitable to engage in the mentalization-based treatment programme.
[40] 	I find that this was entirely appropriate action to take at the time.
[41]	Dr Carville reviewed the Deceased on the 14th June and although she reported a dip in her mood, she denied any current suicidal plan or intent.  
[42]	The Deceased attended with her GP, Dr Barbara Fair on the 17th June 2016 and she was assessed has having low mood.  She also indicated that she was not taking her prescribed medication and that she would buy whatever she needed over the internet. Dr Fair spoke both with Dr Loughrey and with the Deceased’s social worker, who was expressing concerns about the Deceased having suicidal plans. Dr Loughrey advised a change in the Deceased’s medication and she was commenced on Sertraline.  She was also referred that same day by her social worker to the Home Treatment Team.
[43] 	I find that this was both timely and appropriate.
[44]	On the 17th June 2016, the Deceased was assessed by Mr Stewart Buchanan, Mental Health Nurse with the Home Treatment Team. Mr Buchanan noted:
“limited spontaneity and unwilling to discuss historical aspects of the assessment”. 
He also noted that the Deceased’s mood was, “objectively and subjectively low”. The Deceased denied any suicidal plans and that she was taking the antidepressant venlafaxine sporadically. This had not been prescribed to her.
[45]	The Deceased was informed that initially there would be daily home visits from the Home Treatment Team.
[46]	I find that this approach was entirely appropriate. 
[47]	On the 18th June 2016, the Deceased was visited by Mr Michael Corner, Mental Health Nurse.  The Deceased complained about Mr Corner feeling that he was judging her and she asked him to leave her property. The Deceased then contacted the Home Treatment Team and asked that he, Mr Corner, not visit her again.
[48] 	This request was acceded to and I find that this was the appropriate response to the Deceased’s request.
[49]	On the 19th June 2016, the Deceased was seen by Maureen Carlisle, psychiatric nurse. The Deceased is reported to have presented as irritable and that her blood sugars had been unstable due to her erratic eating.
[50]	On the 20th June2016, the Deceased was visited by Dr Saira Tareen, trainee Psychiatrist.  The Deceased denied any active suicidal plans and refused to hand over the medication she said she had purchased over the internet.
[51]On 21st June 2016 Maria Gillespie, psychiatric nurse visited the Deceased. Again the Deceased denied any suicidal plans and again refused to hand over the medication purchased over the internet.
[52]	The Deceased was visited again on the 22nd June 2016, 23rd June, spoken to by telephone on the 25th June and visited on the 26th June. These visits were carried out by Sinead Davis and Mr Buchanan, mental health nurses. Again the Deceased refused to hand over the medication sourced over the internet, her blood sugars were checked and again she expressed no suicidality.
[53] 	At the 25th June 2016 visit, the Deceased indicated to Mr Buchanan that she felt daily visits were too intensive and asked for alternate day visits. This was agreed to but it was also agreed that the Home Treatment Team would telephone the Deceased on the 26th June as opposed to visiting. 
[54]	I find that this was an appropriate approach to adopt at the time.
[55]	On the 26th and 27th June 2016 neither the Home Treatment Team nor the Deceased’s mother were able to contact the Deceased.  As a result, on the 27th June 2016 PSNI were tasked to the Deceased’s property and on forcing entry police discovered the Deceased lying face down on a mattress on the floor in a bedroom.
[56] 	Life was pronounced extinct by a forensic medical officer at 18 Coburg Street, Belfast at 23:35 hours on the 27th June 2016.
[57]	Dr Philip McGarry gave evidence to the Inquest.  Whilst he had not met with the Deceased personally he was aware of the case as he was a supervisor to Dr Tareen, the trainee psychiatrist who had seen the Deceased on the 20th June 2016.
[58] 	Dr McGarry stated that the large majority of inpatients suffer from the most severe forms of mental illness and that a vast bulk of people diagnosed with depression of a non- psychotic nature are treated outside hospital. 
[59] 	Dr McGarry stated that to detain someone who had capacity under the Mental Health Act would be most unusual. He explained that the matter was constantly reviewed but that he was of the opinion and I find that the Deceased did not meet the criteria to be detained under the Mental Health Act at or around the time of her death.
[60]	Dr McGarry explained that the Deceased had a chronic, long standing, persistent problem obtaining medication from over the internet and storing same. She was routinely asked to hand over the medication but refused and the Home Treatment Team do not have a power to remove those medications.  He felt engaging and developing a relationship with the patient was the priority rather than go in with a fairly heavy legal approach.
[61]	In relation to the issue of the Deceased seeking to change Consultant Psychiatrist, Dr McGarry explained that if a patient, such as the Deceased, were to change consultant they would have to change all others in the team that the Deceased would have been familiar with.
[62]	Dr McGarry was of the opinion and I find that there was no gap in care between the 15th November and 16th June as the Deceased remained under the care of Dr Loughrey.
[63] 	A toxicological analysis discovered the presence of Amoxapine and Venlafaxine at well above therapeutic levels. Neither of these drugs had been prescribed to the Deceased and, in fact, Amoxapine is not prescribable on the NHS.   
[64]	A post mortem was performed and it reports and I find that the cause of death was:
1(a).Poisoning by Amoxapine and Venlafaxine.