JO ANNE CAROL NOBBS · Prevention of Future Deaths report

On 3 June 2014 I commenced an investigation into the death of JO ANNE CAROL NOBBS, aged 36 years. The investigation concluded at the end of the inquest on 3 December 2014. The conclusion of the inquest was Medical Cause of Death: Unascertained. Short Form Conclusion: Open.

Miss Nobbs had long standing physical problems and mental health issues. She was diagnosed in 2009 with Borderline Personality Disorder. She did not always engage with professionals. From January 2014 her GP and sister noted deterioration in her mental health. In February 2014 she began to disengage from the various professionals, although continued to self refer to hospital for a variety of physical symptoms. The Community Mental Health Team triaged her on a number of occasions from March up to the date of her death with no success. She stopped collecting her medications on 8 May 2014. Her GP and the Pharmacy called Police to carry out a welfare check on 30 May 2014. Police found her dead in her home on 2 June 2014.

(1) A correlation between Miss Nobbs’ deteriorating physical health and her deteriorating mental health was noted by some mental health professionals and documented in her mental health records but this was not investigated or acted upon by other mental health professionals, despite Miss Nobbs attending at A & E Department, Norfolk & Norwich University Hospital on at least 10 occasions between January and March 2014 presenting with a variety of symptoms and at varying times of day and night

(2) A Care Plan was put in place in January 2014 of steps to be taken on the basis that Miss Nobbs was going to engage with mental health services. The evidence is that this plan was kept under review and was a “continuing” plan. There is no documentation supporting such a continuing plan, particularly when Miss Nobbs was no longer engaging with mental health services. She had not been seen on a 1:1 basis before 26th February 2014 by any of the Community Mental Health Team, save in respect of a believed sighting in the street. There is no evidence of a revised Care Plan being put in place, save in respect of continuing to try to make contact with Miss Nobbs.