Suicide blamed on ‘conspicuous lack of clarity’ for therapy discharge

A “conspicuous lack of clarity” over a comprehensive discharge plan for people receiving mental health support should be blamed for the suicide of a woman from Essex, a coroner has concluded.

Stephanie Moyce had had a lengthy history of mental health issues with episodes of depression from 1990, and a diagnosis of bi-polar disorder in December 2006 before her death on July 31, 2021.

The 55-year-old, who also had a history of alcohol misuse, a documented history of repeated drug overdoses dating back to 2000 and in the seven years or so preceding her death had been hospitalised following impulsive suicide attempts.

Ms Moyce , who also also suffered from a number of complicated physical health complaints, including the after effects of a badly broken leg, and received regular carer support arising from her mobility issues, was last seen by a psychotherapist on June 9 2021 when she was discharged back to the care of her GP from Essex Partnership University Trust.

But evidence called at the inquest into her death in February established that there was no identifiable person responsible within the trust for her on-going care provision, her case had not been discussed at a multidisciplinary team meeting prior to or following her discharge from the psychotherapy and there had been no further care planning following the discharge from therapy.

In a report to prevent future deaths, Sean Horstead, area coroner for Essex, said a number of improvements need to be made by the trust to ensure similar incidents are not repeated.

He said: “Evidence confirmed a conspicuous lack of clarity as to who, amongst EPUT clinicians/staff, is responsible for ensuring that a clear and comprehensive discharge plan is formulated for those coming to the end of a course of psychotherapy where a care coordinator is no longer in place/has not been replaced.

“Evidence confirmed a conspicuous lack of clarity as to who, amongst the trust clinicians/staff has the responsibility for oversight of patient care following discharge, including responsibility for ensuring adequate and appropriate safety netting is in place in the event of relapse, where a care coordinator is no longer in place/has not been replaced.

“Evidence confirmed that patients under psychotherapy are not presently routinely discussed in the locality multi-disciplinary team meetings prior to their discharge leading to a missed opportunity.”

He 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.”

Paul Scott, the trust’s chief executive, said: “Our condolences go to the friends and family of Stephanie Moyce at this difficult time.

“We are closely looking at the recommendations that the coroner has made and have already put in place a number of steps to ensure that the discharge process better takes into account individual needs and that there is improved collaboration across different teams and services.

“Our staff work tirelessly to give the best possible care to our patients in often difficult circumstances and the Trust is focused on making sure that we learn lessons from any tragedies of this nature.

“With an average of 100,000 patients using our services at any one time we are committed to constantly improving the care that we give our patients and service users.”

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Piers Meyler

Local Democracy Reporter