Janette Insley · Prevention of Future Deaths report

On the 5th December 2014, I commenced an investigation into the death of Ms Janette Insley.

The Deceased had a longstanding history of depressive illness. In May 2014 her mental and psychological health deteriorated markedly resulting in her admission to a mental health unit as an informal patient. She declined pharmaceutical intervention on the basis that she believed she was suffering from Protracted Withdrawl Syndrome and that medication was responsible for her signs and symptoms. The doctors caring for the deceased did not share this view, their diagnosis being that the deceased was suffering from traits of personality disorder and an inability to cope with psychosocial stressors. They felt that there was no evidence of a biological depressive disorder during the course of the index admission. Upon this basis, the hospital doctors considered that referral to a Psychologist for care and treatment was the most appropriate course of action.

Discharge planning was commenced and halted on several occasions due to episodes of serious self-harm by the deceased, including attempts at self-ligature and overdose.

During the course of her inpatient stay, the deceased was allowed time off the ward/leave away from the ward, subject to risk assessment by care staff. On the whole, whilst very stressful for the deceased, periods of leave passed without incident.

However, on the 3rd August 2014 the Deceased failed to return to the ward following afternoon home leave. Enquiries were made by ward staff and the deceased’s ex-partner/friend in an attempt to make contact.

Ms Insley was subsequently found deceased at her home address later that evening, having self-ligatured.

1. During the course of the evidence I was told that whilst the Consultant Psychiatrist considered that a referral to a Psychologist was the most appropriate course of treatment available, staff were unable to make any such referral for inpatients due to lack of i) availability of suitably qualified practitioners and ii) resources. There is therefore a clear service gap.

2. I was also told that most, if not all, Psychological therapy now takes place within the community. It would appear that undue emphasis is currently being placed upon this setting of care, to the detriment of inpatient services.

3. That any referral to/consultation with a Psychologist based within the community would have taken at least 3-4 weeks post-discharge, thus leaving the patient without therapy during a particularly vulnerable period.