Student Health Service

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First report 16 May 2019•Latest report 16 May 2019

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 Student Health Service linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Avon

    AI-generated summary

    Natasha Elizabeth Victoria Abrahart · 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

    Natasha Elizabeth Victoria Abrahart died on 30 April 2018 after placing a ligature around her neck. She was under the care of a mental health team that had not provided a timely and detailed management plan following several assessments. The report also identifies concerns that follow-up after starting sertraline, including review of suicide risk, did not comply with the cited NICE guideline; the inquest concluded that the death was suicide contributed to by neglect.

    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 Student Health Service; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to arrange timely follow-up review after starting antidepressants for people at increased suicide risk or younger than 30 years

    Wider context from the report

    “The NICE guideline Depression in Adults: Recognition and management (CG90) states in section 1.5.2.7 “A person with depression started on antidepressants who is considered to present an increased suicide risk or is younger than 30 years (because of the potential increased prevalence of suicidal thoughts in the early stages of antidepressant treatment for this group) should normally be seen after 1 week and frequently thereafter as appropriate until the risk is no longer considered clinically important” In this case Sertraline was prescribed but the NICE guideline was not followed by the mental health trust or the GP practice. The expert indicated that the review at 1 week is to ensure that the patient is taking the medication, to check for any side effects including suicide risk and to see what has happened; that review can be done by the G.P. or the mental health team but there needs to be a known appointment. ”
    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