Jessica de Souza · Prevention of Future Deaths report

Following an inquest opened on the 14th February 2023 the inquest was concluded on the 16th April 2024.

The cause of death was:

1a.) Suspension

The conclusion was Suicide.

Jessica de Souza was diagnosed with bipolar disorder. She suffered an acute manic episode in the summer of 2022. She was detained under section and prescribed aripiprazole. Her condition stabilised. She was discharged to the Home Treatment Team on the 10th November 2022.

On the 1st December 2022 her care was transferred to the Community Mental Health Team. She was offered an appointment to see her community psychiatrist on the 19th December 2022 but the appointment letter arrived after that date. The appointment was rescheduled for the 16th January 2023.

She suffered a family bereavement on the 16th January 2023 and rang cancelling the appointment. She was spoken to by the psychiatrist and offered a further appointment on the 30th January 2023 when she rang saying she wasn’t feeling well following her bereavement.

She was not seen face to face for an assessment by either her community psychiatrist or her care coordinator. Support was not put in place by the community team following the bereavement. Her family were not given information about signs of relapse. Her prescribed medication, aripiprazole, was not effective to prevent her developing a depressive episode.

She developed depression and took her own life by hanging herself at her home at ████████ on the 1st February 2023.

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.