LISA MARIE THOMPSON · Prevention of Future Deaths report

On 16 March 2020 an investigation was commenced into the death of LISA MARIE THOMPSON . The investigation concluded at the end of the inquest on 19th November 2020 . The conclusion of the inquest was Suicide. The medical cause of death was

1a Hypoxic Brain Injury, 1b Cardio Respiratory Arrest, 1c Asphyxiation , 1l Depression

Lisa was found unresponsive at home at approximately 10:30 on 14th March 2020 having tied a ligature around her neck and attaching this to the spindle of the staircase with the intention of ending her life. She was resuscitated and conveyed to the John Radcliffe Hospital where she died of an Hypoxic Brain Injury due to cardiorespiratory arrest caused by asphyxiation.

Lisa had taken significant overdoses of her prescribed medication for severe anxiety and depression in December 2019 and January, February and March 2020 each time minimizing her actions despite apparent escalation of her behaviour, assurances each time this was impulsive and, she would not do it again. She was sensitive to the side effects of medication and reported no beneficial effects. She was known to be in crisis during this period and was prescribed diazepam on 10th March and reviewed by a new psychiatrist on 13th March. Her explanations of her overdoses were not consistent with her actions and contained inaccuracies, she was not challenged about this by the mental health team. Her care plan and risk assessments were not up-to-date.

Evidence was heard that:

(1) There was no clear care plan in place following an emergency review of Mrs Thompson on 13th March 2020

(2) The care plans and risk assessments at the mental health Trust were not updated:

(a) with material information on the facts and circumstances of Mrs Thompson’s overdoses of her medication.

(b) the two most recent overdoses were not recorded

(c) with further information disclosed by the doctor who treated her most recent overdose that Mrs Thompson had lied about the severity of her overdose that it was probably double that which she initially disclosed also that this was her 4th overdose and another could not be ruled out.

(d) on 13th March 2020 following a review with the Trust Consultant Psychiatrist

(e) on 13th March 2020 when there was a telephone conversation between Mrs Thompson and her care co-ordinator