A woman sent to King George Hospital after taking two overdoses in two days was discharged and deemed at “low” risk of harming herself, an inquest heard.
Trinder Birdi, 34, died in King George Hospital on February 14, two days after being found unresponsive in her Ilford home.
An inquest held at Walthamstow Coroner’s Court on November 17 found she died from “the likely effects of drug toxicity”, most likely after overdosing on legal medication.
Senior coroner for East London Nadia Persaud said it would be “complete speculation” to rule Trinder’s death could have been avoided but found her mental health assessment at the hospital was “lacking in robustness” and failed to consider her history.
Trinder was sent to King George’s A&E on January 29 by her GP, who became concerned she was at serious risk of harming herself after seeing her earlier that day.
She was discharged by a nurse from North East London Foundation Trust (NELFT) and referred for community support. The team was unable to reach her before her death.
Her brother, Dr Harjot Singh Birdi, told the inquest: “We as a family are very upset that she was discharged by the hospital.
“The referral letter (from her GP) clearly outlined that she was severely depressed and suicidal. She had already admitted two overdoses and felt she would do so again.
“We are extremely concerned as she had actively sought help and had told the GP. She passed away within weeks of these cries for help.”
He added that her suffering had come as a surprise to the family, as she had not “disclosed her mood or feelings” and seemed normal in the period leading up to her death.
Trinder saw Dr Sambhavi Sheedy, at Ilford Lane Surgery, twice in January, complaining of low mood since the start of the year and explaining it was unusual for her to be low for so long.
She could not identify anything that had caused the change but said she was struggling at work, had lost her appetite and was not enjoying her normal hobbies.
During their second appointment on January 29, she admitted she had taken two overdoses of legal medication, one impulsively and then a second, larger overdose the following day.
Dr Sheedy told the inquest Trinder described “something snapping in her” and that, while apologetic, she “denied having regrets and would not assure (Dr Sheedy) she would not do it again”.
In her letter to the team at King George, Dr Sheedy wrote there was a “significant risk of Trinder overdosing, possibly at a higher dose” in future.
The inquest also heard from Lynn Christoforou, the mental health liaison team nurse who assessed Trinder over the course of about an hour at King George Hospital that same day.
Explaining her decision to deem Trinder a “low risk”, she said: “She spoke about her future in a positive way and said she was relieved she had not done any damage to herself.
“I asked her a few times about her suicidal ideation and she completely denied that she was feeling suicidal.”
Ms Persaud said: “I’m struggling to understand how she could go from being a high risk to someone who knows her well to being a low risk with someone meeting her for the first time.
“It sounds like you placed a lot of weight on her words and her presentation but a risk assessment is about factoring in her history, the views of professionals and her actions.”
Ms Persaud suggested that, after more than four hours in A&E, Trinder may have wanted to leave and was “probably not telling the truth”.
She explained she was not blaming Ms Christoforou and accepted Trinder could not have been detained under the Mental Health Act but perhaps been referred with “more urgency”.
Dr Sheedy saw Trinder a final time before her death, at a follow-up appointment on February 5, and reported she was “quite adamant she would not do it again”.
She told the inquest: “When she walked out of my room on that day, I thought she would not make a repeat attempt. I felt she was back in control.”
NELFT’s assistant integrated care director for mental health Kevin Sole told the inquest the trust had conducted a serious investigation into Trinder’s death and had learnt from it.
He said: “There’s a real lesson to learn here with the benefit of hindsight. We need to develop a system for getting a more comprehensive assessment, maybe a second opinion.”
Ms Persaud concluded: “I will be writing to the trust to raise my concern.
“Where the risk assessment by the psychiatric liaison team is at odds with that of a medical practitioner, there should be safeguards before the patient is discharged.”