BMJ Publishing Group Limited

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First report 16 Jul 2024•Latest report 16 Jul 2024

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from BMJ Publishing Group Limited linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Surrey

    AI-generated summary

    Jessica de Souza · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Jessica de Souza, who had bipolar disorder, developed depression after a family bereavement and took her own life by hanging at home on 1 February 2023. Concerns included that aripiprazole was prescribed as monotherapy for both polarities of bipolar disorder, although expert evidence stated it was not effective prophylaxis against depressive relapse. The expert also considered that the guidance relied on by clinicians may have been misleading.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to BMJ Publishing Group Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure aripiprazole monotherapy is effective for prophylaxis against both bipolar polarities

    Wider context from the report

    “i. The treating psychiatrists gave evidence that, following the acute manic episode, Jessica was prescribed aripiprazole as a maintenance prophylactic drug to control both polarities of bipolar disorder. ii. The clinicians relied on the BNF and the BMJ Best Practice Bipolar Disorder in Adults to support their decision to prescribe aripiprazole as prophylaxis for both polarities as a monotherapy. iii. Nice Guidance on Bipolar Disorder [CG185] suggests aripiprazole may be considered as a maintenance treatment to prevent relapse in bipolar disorder. iv. The BMJ refers to aripiprazole being used as a monotherapy to treat bipolar disorder, though does advise that it is more effective in preventing mania than depression. v. The court appointed psychiatric expert gave evidence that aripiprazole is not effective as a prophylaxis in relation to the depressive polarity in bipolar and that as a result Jessica was not protected from a depressive relapse. vi. The expert considered that the guidance relied on may have been misleading for the clinicians. ”
    Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026