Michaela Louise Thompson · Prevention of Future Deaths report

On 2nd December 2015 I commenced an investigation into the death of Michaela Louise Thompson, age 36. The investigation concluded at the end of the Inquest on 19th October 2016. The conclusion of the Inquest was a Narrative, a copy of which I attach. The medical cause of death was:-
(1a) Hanging

The deceased was separated from her husband and lived with her two children aged 5 and 10, and had a medical history of suffering with depression. Mrs Thompson believed that she was suffering with a borderline personality disorder and/or bipolar disorder. These conditions had not been formally diagnosed. Miss Thompson had a long association with mental health services and was fully compliant with all treatment options. She had not been seen by a psychiatrist nor had any mental health assessment. She had regular suicidal thought culminating in her taking her own life by an act of self-suspension at her home address, her death being confirmed there at 1724 hours on 1st December 2015.

(1) Michaela was the subject of two multi-disciplinary team meetings which were inadequately documented in the case notes. It should be clearly documented as to who was present and participating in such meetings. The identification of those involved should be clearly recorded, as should the outcome of and decisions made at such meetings.

(2) On the morning that Michaela Thompson died, she had telephoned Aire Court in the presence of a friend who noticed that she became anxious and upset during that brief call. There was no record kept as to the nature of the call or any information or advice given, nor was the fact of the call immediately communicated to the Community Mental Health Nurse involved. Calls to the Service should therefore be recorded, to ensure that details of the nature of the call; its urgency; and the action taken by a named individual or individuals can be clearly ascertained.