Delay in giving anti-psychotic medication contributed to death of Chelmsford woman

A delay in prescribing and administering anti-psychotic medication contributed to a death of a mentally unwell woman in Chelmsford, a report has concluded.

Coroner Sonia Hayes has now written to Essex Partnership University NHS Foundation Trust detailing her concerns around the circumstances leading to the death of Bency Joseph – including delays in responding to her rapidly deteriorating mental state.

Ms Joseph died instantly on May 27 2022 from following a headfirst fall from an upstairs window at her Chelmsford home. A report said she did not have the capacity to decide to take her own life.

Ms Joseph had been suffering with recent mental health issues and attended Broomfield Accident & Emergency Department on May 24 with acute psychosis.

She was assessed by a mental health team Mental on May 25 and referred to the Home Treatment Team and the First Episode Psychosis Team.

Medication was prescribed and administered on May 25 2022 at hospital and she discharged under the care of the Home Treatment Team.

On May 26 the home treatment team consultant psychiatrist found that she had deteriorated and prescribed urgent anti psychotic anti-anxiety and -medication to be provided on the same day. The medication was not provided.

A statement as part of a report from coroner Sonia Hayes to prevent future deaths said: “It is unclear if the urgent prescription was received and processed.

“The family’s concerns and attempts to escalate the failure to provide the medication were not actioned by the Trust and the death occurred in the early morning of May 27 as the family were making arrangements to take her back to accident and emergency due to the omission to provide medication and further deterioration.”

A statement from the coroner referring to the conclusion of the inquest added: “There was delay in the provision of antipsychotic and anxiolytic medications to Bency Joseph during a four-day period in May 24 – 27 2022 and this contributed to her death during a severe psychotic episode with a medical cause of death of ‘1a Traumatic head injury, 1b Fall from height.”

She added that the trust investigation did not inform or involve the trust senior pharmacist who was unaware of the death and had no opportunity to be involved in the internal investigation, involve the family of the deceased and lost an opportunity to understand concerns that the family had been trying to access additional urgent medication prescribed on May 26 2022 without success and had been telephoning the trust to raise an alert.

She added: “In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action.”

A spokesperson for Essex Partnership University NHS Foundation Trust (EPUT) said: “Our sympathies remain with Bency’s family, friends and loved ones at this difficult time.

“We are committed to providing the best patient care and are taking action to ensure learning from this tragic incident is shared and firmly embedded across the trust to drive forward improvement.

“We will respond to the coroner in due course.”

Piers Meyler

Local Democracy Reporter