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A psychiatrist has spoken of his regret that he discharged teenager Gaia Pope-Sutherland from hospital just weeks before her death without any community mental health support, an inquest heard.
Dr Peter Jeffery completed a Mental Health Act assessment in the early hours of October 22 2017 after the 19-year-old’s worried family took her to Poole Hospital.
He decided she did not require admission to a psychiatric unit and instead sent her home with a summary of her hospital admission being sent to her GP, Dorset Coroner’s Court heard.
Just weeks later, on November 7, Miss Pope-Sutherland was reported missing from her home and her naked body was found dead 11 days later on cliff tops in undergrowth. She had died from hypothermia.
The college student, 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.
Dr Jeffery, who at the time was a registrar but is now a consultant, told the hearing in Bournemouth that he did not discuss with Miss Pope-Sutherland the community-based support, such as therapy services, she could receive or speak properly with her uncle, with whom she was staying.
“I think that is one of the regrets,” he said.
“There are two regrets I have from this particular case. One is that I didn’t discuss with the uncle the insight we gained throughout the day, I think that would have been incredibly helpful.
“I think it would have been incredibly valuable to have had that conversation and that is one of my regrets.
“I think there was the opportunity to refer her back to Steps to Wellbeing and I have to acknowledge that didn’t happen, and that was an omission.”
Dr Jeffery told the inquest he concluded that the teenager’s presentation that day was linked to her epilepsy and the result of a seizure a few days previously, and he prescribed her diazepam for seven days to help with the condition.
Sarah Clarke QC, counsel to the inquest, said this was the fourth time in two years Miss Pope-Sutherland had been seen by psychiatric services, including being sectioned under the Mental Health Act in February and March of 2017.
“She is 18-years-old and she is now in hospital again with another what appears to be psychotic symptoms and although she has not been sectioned she has gone through another Mental Health Act assessment,” Miss Clarke asked.
“Was there any thought given to giving advice to the family about what to do if something like this happens again?”
Dr Jeffery replied: “I think our focus of the assessment and our conclusions were this is related to her epilepsy, and our primary intervention of choice is to gain epilepsy control.
“We knew that had been problematic, medicines didn’t work, and she was being considered for neuro-surgery.
“Even though there are neuro-psychiatric presentations, the issue is from our assessment is that this is about getting control of her epilepsy.
“I think that probably interfered in the thinking at the time and dominated the thinking at the time.”
Dr Jeffery also said that despite knowing she was under the care of neurologists in London and Dorset, he did not speak with them.
“I think there was a working assumption Gaia was being considered for surgery and was actively engaged in that process,” he said.
“I think that is a reflection that is valid and we could have communicated with neurologists our assessment and added value to their understanding.
“We considered the GP would be the hub of that and the GP would know about the neurology referral, and would be the source of that information getting back.”
Dr Jeffery disagreed with the assertion there was no follow-up plan for the teenager.
“I would challenge the fact there wasn’t any management plan, if we accept the management plan was to try and address the primary issue of epilepsy control and being prescribed a medication that would reduce epilepsy frequency,” he said.
“We are engaged in a contextual assessment for the purposes of the Mental Health Act, and I agree there are some additions that are really beneficial which includes liaising with the neurologists.
“I think the missed opportunities here were that we could have reassessed the link between Gaia and the Steps to Wellbeing service for consideration of trauma-based work.
“There was a real opportunity to liaise with the neurologists and I think I could have added real value by speaking directly with the neurologists to contextualise the assessment.”
The inquest was adjourned until Friday.