Young woman's suicide sparks concerns over 'lack of information sharing'

A coroner has expressed her concerns over "a lack of information sharing" after a 25-year-old Cheshire woman took her own life. Evie Jane Davies was found dead at her home on December 2, 2021, "having taken a significant overdose of medication which had not been prescribed to her".

An inquest concluded on May 1 that her death was suicide. Now Victoria Davies, area coroner for Cheshire, has written to organisations Spider Project Café 71, Cheshire and Wirral Partnership NHS Foundation Trust and the former West Cheshire Clinical Commissioning Group to report her worries.

In a prevention of future death report, she states that Evie had been struggling with her mental health for several months and after receiving "unwelcome news" on the day before her death, she "called the crisis line and was directed to the cafe71 service". The coroner is concerned that the Café 71 team operate "in isolation" so were unaware of Evie's background, plus there is then no notification made to the mental health team that a call had been made so they can follow-up.

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Describing the circumstances around her death, the report said: "It is likely that this was a deliberate act with the intention to end her life, contributed to by a deterioration in her mental health which commenced in June 2021 following the unexpected death of her partner, and was compounded significantly over the following months by on-going family proceedings regarding her children, lack of regular contact with her children and a forthcoming criminal hearing which she perceived would also impact upon her ability to be with her children.

"In the six-month period prior to her death, Evie was being supported by the mental health team (part of CWP), had an allocated care co-ordinator until November 2021, and in the last few weeks before her death was under the home treatment team. The mental health team supporting her were aware of her on-going stressors and that 3 December was a key date for Evie, the anticipation of which was significantly affecting her mood.

"On 1 December Evie received some unwelcome news. It is described by the GP that she called the crisis line and was directed to the cafe71 service. There were no notes of this call available to the inquest as the pro forma supplied to the GP is blank but it is likely, given what we know of the background circumstances and the subsequent events, that she shared some distress during this call."

The report concludes: "During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you.

"The evidence I heard was that the café71 service is run as a crisis line for those who are in ‘lesser crisis’ than those who would call the mental health team crisis line or the crisis resolution home treatment team. It appears that the cafe71 team is operating in isolation/ separately to the mental health team, and for those patients who are under the mental health team, they will be unaware of the background and the risk factors for that person.

"They will take an assessment of that person at face value based on how they are in the call, as they don’t have access to the information held by the mental health team. In addition, there does not appear to be any notification to the mental health team to say that the person has been in contact such that this can be followed up.

"It is likely that there is notification to the GP but in this case there was no detail provided which could have been passed on, and the timescales for review of correspondence by the GP, who again are operating somewhat in isolation to the mental health team, does not lend itself to the prompt action which may be required by the mental health team.

"I am concerned that the lack of information sharing between the organisations, and in particular in real time or as near as possible, gives rise to a risk of future deaths and consider that your organisation has the power to take action, either as provider of the service or as commissioner."

A statement issued on behalf of Cheshire and Wirral Partnership NHS Foundation Trust (CWP) and Spider Project Café 71 said: "We offer our sincerest condolences to Evie’s family and loved ones, and they remain in our thoughts during this difficult time. Since 2021 we have taken a number of actions to support appropriate information sharing and will be responding directly to the coroner outlining our action plan in full."

A spokesperson for NHS Cheshire and Merseyside said: "NHS Cheshire and Merseyside acknowledges the findings of the report, and our thoughts are very much with Evie’s family and friends. We are working with partners to review and respond to the findings, in order to determine actions and embed lessons learned."

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