There were “missed opportunities” in the communications between the specialist doctors treating teenager Gaia Pope-Sutherland before she disappeared, an inquest heard.
The teenager, who suffered with severe epilepsy, was found dead near cliffs 11 days after she went missing from her home in Swanage, Dorset in November 2017.
As well as epilepsy, Miss Pope-Sutherland had been diagnosed with post-traumatic stress disorder after disclosing she had been raped by a man when she was 16.
Dorset Coroner’s Court heard evidence from neurologist Professor David Chadwick, who had been called to give his opinion on the care the 19-year-old had received.
She was diagnosed with epilepsy in 2013 and in November 2016 referred to a specialist in London, because her family wanted a second opinion. She was seen in March 2017 and recommended for brain surgery.
Prof Chadwick, an emeritus professor of neurology at the University of Liverpool, told the court Miss Pope-Sutherland had “severe and complex” and “unusual” epilepsy.
Asked how bad her epilepsy was, he replied: “It is being at the wrong end of the spectrum of severity that one is as likely to see.
“I would almost say she is unique in my experience. I have not come across the features she presented in my clinical practice.”
He told the court there was a “complex relationship” between epilepsy and mental health, and said that sufferers often struggled with anxiety and depression and could develop postictal psychosis after a seizure, which can “last for hours to days, possibly even a week or so”.
“I cannot exclude the possibility that her abnormal behaviour was a manifestation of a postictal psychosis,” he said.
“I don’t have the expertise to say that she had a psychological disorder as well as epilepsy.”
Miss Pope-Sutherland had been assessed by psychologists on three separate occasions between December 2016 and October 2017.
This included a period in a mental health unit in the February and March, but doctors had not informed the neurologists treating her epilepsy.
Prof Chadwick described this failure as a “missed opportunity” to review her epilepsy care.
Explaining why, he said: “It may well have been that changes might have been made to her anti-epilepsy drug treatment, but I think we were getting to a stage of a point in time where a significant improvement in the condition of her epilepsy was low.”
In July 2017 Miss Pope-Sutherland underwent a series of tests as part of her surgical assessments, but neuropsychiatric and psychological evaluations were omitted, despite a request for them, which Prof Chadwick also described as a “missed opportunity”.
Rachael Griffin, the senior coroner for Dorset, asked Prof Chadwick whether these collective failures amounted to neglect.
He replied: “I have difficulty answering that question because I am not quite certain about using the word ‘gross’, as if by gross you mean the effect of those omissions had a significant effect in the outcome that we are all very much aware of, then I wouldn’t use that term.
“If one says getting one thing wrong is perhaps excusable, but perhaps three or four things wrong you might use the term gross.”
He described Miss Pope-Sutherland’s overall epilepsy care as “reasonable” but said he would have expected her to be seen by a neurologist after July 2017, which never happened.
The court heard that Prof Chadwick was unable to say whether Miss Pope-Sutherland’s epilepsy contributed to her death.
Ms Griffin asked him: “You cannot say on the balance of probabilities that epilepsy contributed to Gaia’s death more than minimally, negligibly, or trivially?”
Prof Chadwick replied: “I think that’s right. On the balance of probabilities that epilepsy was a factor in Gaia’s death? I cannot say that.
“Could it have been? It’s possible that epilepsy was very much a cause of her death – that is certainly a possibility because we know isolated seizures can result in sudden death.”
The inquest continues.