Evelina Vilkiene · Prevention of Future Deaths report

On the 20th June 2022 I commenced an investigation into the death of Evelina Vilkiene aged 45 years. The investigation concluded at the end of the inquest on 2nd March 2023. The conclusion of the inquest a narrative conclusion:

Evelina Vilkiene took her own life whilst under the care of the mental health services. She was at increased risk of harm to herself following a decision to wean her clonazepam medication on the 26 May 2022, but there was no careful risk management plan and there were no significant assessments of her mental health following the 27 May 2022”.

Evelina Vilkiene suffered from a first psychotic episode in November 2021 and required care from the mental health services. She was admitted to the care of the intensive home treatment team and then transferred to the care of the early intervention in psychosis team. In April 2022 she presented in crisis again, presenting with severe depression. She was accepted again by the home treatment team and remained under their intensive support until 21 May 2022. There was no detailed risk assessment at the time of step-down, or jointly agreed risk management plan. At the time of step-down she presented as anxious in relation to her medication and showed a dependence to clonazepam. A medical plan was set to wean her off the clonazepam on the 26 May 2022, with no carefully devised risk management plan put in place. There was no care co-ordinator visit following the medical review on the 26 May 2022. On the 7 June 2022, Evelina was found hanging in the basement of her home address. A paramedic pronounced her life extinct on scene. Police deemed the circumstances as non-suspicious. A note was found which contains Evelina's stated intention to take her own life.

1. When Evelina was stepped down from the Home Treatment Team to the Early Intervention Psychosis Team, there was no detailed risk assessment or jointly agreed risk management plan.

2. On the 26th May 2022 when a decision was made to wean Evelina from the Clonazepam medication there was no detailed risk assessment or risk management plan. It was agreed in evidence that there was an increased risk to self at this time. No additional steps were put in place to ensure insofar as possible, that Evelina was kept safe.

3. Following the medical review on the 26th May 2022 there were no further care co-ordinator reviews. This was in contravention of the general requirement for amber zoned patients to be seen at least weekly.