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A psychiatrist has admitted the information sent to the GP of teenager Gaia Pope-Sutherland when she was discharged from hospital just weeks before her death was inadequate, an inquest heard.
The 19-year-old’s worried family took her to Poole Hospital on October 21 2017 because of concerns about her deteriorating mental health.
She was admitted to the hospital for an assessment under the Mental Health Act which was carried out the following day by registrar Dr Peter Jeffery, a second doctor and another practitioner.
Dorset Coroner’s Court has heard that Miss Pope-Sutherland did not meet the criteria to be detained under the Mental Health Act and was able to go home with her family.
Just weeks later, on November 7, Miss Pope-Sutherland was reported missing from her home and her naked body found dead 11 days later on cliff tops in undergrowth. She had died from hypothermia.
The teenager, who suffered from severe epilepsy and post-traumatic stress disorder, had been experiencing “ongoing manic episodes” and was also worried about the imminent release from prison of the man she had accused of raping her.
The inquest at Bournemouth Town Hall heard Miss Pope-Sutherland’s discharge summary was written by a nurse and sent to her GP, but did request any follow-up action.
The note said: “Brought into the emergency department by mother with repetitive speech and aggression, upset with high energy.
“Medically therefore no issues and therefore psychiatric liaison team to review. Medically stable for discharge.
“Patient persuaded to stay for Mental Health Act assessment without need for sectioning. Assessed as low risk retaining compacity.
“Addition of 2mg diazepam as required twice a day. Safe to be discharged to family.”
Asked about the summary, Dr Jeffery said: “There was no specific action but for the GP to be aware of the presentation, but I agree that does not give a very good description of the position.”
Rachael Griffin, the senior coroner for Dorset, asked: “If I had got that as a GP, I would have filed it and not thought I needed to do anything.”
Dr Jeffery replied: “I would agree.”
Ms Griffin asked: “That’s not the case, is it?”
The psychiatrist, who is now a consultant, replied: “No, that’s not the intended case, it was intended to make the GP aware of an episode of admission.”
The court heard the discharge summary made no reference to referring Miss Pope-Sutherland to neurology specialists about her epilepsy, which Dr Jeffery accepted was an omission.
“We’ve since improved that process where the approved Mental Health Act practitioner is responsible for furnishing the GP with a report and we hope that will be more psychiatric-orientated and a bit more useful,” Dr Jeffery said.
He added: “I think the quality of the discharge summary is variable and very much depends on who writes it.”
The inquest continues.