Prevention of Future Deaths report - Samantha Gould (28 May 2021)

Summary

Samantha Gould was 16 years old when she died by suicide due to an overdose of prescribed medication on 2 September 2018. She had borderline personality disorder that meant she was at risk of deliberate self-harm and suicide.

In this report, the Coroner highlights concerns about a systemic weakness in the way in which Child and Adolescent Mental Health Services and primary care communicate with local pharmacies concerning 16-18 year old patients who are at risk of deliberate overdose. In spite of a safety plan agreed with Sam’s consultant psychiatrist whereby Sam’s parents would be responsible for her medication, Sam was able to pick up older prescriptions on 1 September 2018 without challenge, and it was those medications that were fatal in the combined amounts ingested by Sam.

Content

In his report, the Coroner raised the following concerns:

1. There did not appear to be any national guidance or standards that directed or encouraged appropriate sharing of risk information and care plans with the local pharmacy. As a result, the pharmacy was unsighted on the fact that the treating psychiatric team had a safety plan involving Sam’s parents being responsible for handling and administering all medication. Had the pharmacy been aware of this plan, it is likely that they would either have refused to provide the medication with which Sam overdosed or, at least, contacted Sam’s parents or General Practitioner.
2. A local protocol has now been introduced whereby the Cambridgeshire and Peterborough Foundation Trust’s Child and Adolescent Mental Health Service ensures that any pharmacy used regularly by their patients aged 16-17 are (where appropriate) advised of relevant care plans, as well as the responsible GP being so informed. This is now to be part of mandatory training for CAMHS prescribing staff and is to be discussed in the local Joint Prescribing Group to ensure better communication between the local NHS Trusts, G.P.s and local pharmacies. Accordingly, action has already been taken in the local area to prevent similar fatalities.
3. However, I am concerned that there is a risk of future fatalities if action is not taken at a national level to ensure that pharmacies are appropriately involved in medication safety plans for mental health patients aged 16-17, given that such patients may otherwise be able to obtain prescribed medication with which to overdose. 

This report has been sent to The Royal Pharmaceutical Society, The General Pharmaceutical Council, The Company Chemists’ Association and NHS England.