GP knew teenage patient’s suicide plan but did not tell parents

Isobelle Phipps was 17 when she visited her doctor and outlined her specific suicide plan.
Isobelle Phipps was 17 when she outlined her specific suicide plan to a doctor - HNP Newsdesk/Hyde News & Pictures Ltd

A GP knew a teenage girl was planning her own death but did not tell her parents, it has emerged.

Isobelle Phipps was 17 when she visited her doctor and outlined her specific suicide plan. The GP did not tell Isobelle’s family but did make a referral to a mental health crisis team.

A “misunderstanding” between NHS hospitals and mental health specialists resulted in the referral being rejected and still nobody contacted Isobelle’s family.

She died the next evening, on Saturday, April 29 2023, at her family home in Cookham, Berkshire.

Sarah Renton, Isobelle’s mother, is a nurse who is now urging any GPs in a similar situation to inform the parents of a child who appears at risk of harming themselves.

Isobelle, known as Issy, had gone to see her GP the day before her death and revealed a detailed plan of how she would take her own life. She also collected a prescription for antidepressants on the same day.

Her GP was in Gloucestershire and close to her boarding school of Hartpury College, where she was an avid rugby player and studying for A-levels in PE, Psychology and English.

‘Complex’ case

Isobelle’s family went to Wales to watch a rugby match on the Saturday morning, while she went to Twickenham to watch the Six Nations. She was pronounced dead at her family home later that evening.

It emerged that the Gloucestershire-based doctor contacted Isobelle again later on the Friday after her morning appointment.

Dr Mostapha Hassan, a trainee GP working at Staunton and Corse, said the case was “complex” and asked for advice from his supervisor, Dr Mungo Chambers. The advice did not involve telling her family.

A referral was made to a crisis team at Gloucestershire Health and Care NHS Foundation Trust who then approached colleagues in nearby Berkshire, where Isobelle was staying for the weekend.

Berkshire Healthcare NHS Foundation Trust would not accept the urgent referral because it needed to come from a GP and Issy was not registered with a Berkshire GP.

At the inquest last month, this was called a “misunderstanding” by an official at Berkshire Hospital who said it should have accepted the referral. As a result, no healthcare professionals reached out to the family of Issy.

Coroner Alison McCormick said at the conclusion of a two-day inquest: “If Issy’s parents had been told of Issy’s plan on April 28 2023, they would probably have been able to take swift steps to ensure that Issy was not home alone.”

She added that the failure of health services to communicate the risk to Issy’s parents “made a more than minimal contribution” to her death.

The Princess of Wales embraces Isobelle's mother Sarah Renton at Maidenhead Rugby Club last summer
The Princess of Wales embraces Isobelle’s mother Sarah Renton at Maidenhead Rugby Club last summer - Vagner Vidal/Hyde News & Pictures Ltd

Ms Renton has wondered, in the 18 months since Isobelle’s death, if her daughter was having second thoughts.

“I do wonder if part of it was a whim because there was a katsu chicken curry on the side [in the kitchen], which was her favourite meal,” she told The Sunday Times.

“It was like she’d got it out of the fridge to heat up and then she just thought, ‘No’.”

Medical guidance for GPs who are dealing with concerns about a patient self-harming or having thoughts of suicide does advise the doctor to contact parents if there are safety concerns.

“As a nurse, I feel there was an absolute lack of duty of care shown to Issy,” Ms Renton said.

“I’ve spoken to a lot of GPs since and they’ve not met another GP that wouldn’t call the parents.

“You hear awful stories about universities when someone kills themselves and then they find out there’s been other attempts and nobody’s told the family. That shouldn’t be happening with schoolchildren.”

‘Work ongoing to prevent similar outcomes’

The Berkshire Hospital Trust said it now has processes in place to “improve communication in cross-border referrals” and the Gloucester Health and Care NHS Foundation Trust added that work is ongoing to “prevent similar outcomes in the future”.

The Princess of Wales visited Maidenhead Rugby Club last summer and gave Ms Renton a strong embrace. Isobelle had links to the club from when she started playing there aged just four.

The Princess received a pair of gold earrings from Ms Renton, which were made by Isobelle’s niece, and the Princess donned the jewellery a few months later on World Mental Health Day in October.