Carol Ann Guest · Prevention of Future Deaths report

On 9 April 2024 I commenced an investigation into the death of Carol Ann Guest. The investigation concluded at the end of the inquest . The conclusion of the inquest was

Suicide.

1a Hanging

1b

1c

II

Carol Ann Guest resided at home with her partner and did not have a history of mental health problems until 2024. These appear to have been triggered by her mother (for whom she had been caring for a considerable period of time) being admitted to a care home. There were references in the GP notes to Ms Guest and her family seeking help and support in relation to mental health difficulties, which the family felt were escalating. On the 8th March 2024 a family member contacted the GP expressing concerns regarding escalation of symptoms and Ms Guest having taken excess medication the previous week. The GP did not feel a telephone call that day was indicated but did feel that urgent referral was necessary but regrettably the urgent referral was not sent until a week later. Once received by yourselves on Friday the 15th March, Mrs Guest's referral was placed on the SPA meeting list for the following Thursday (the 20th March) where it was discussed and determined that she would not follow the usual pathway and wait for a routine appointment but that a consultant would visit her the following week. Before that visit could be arranged Ms Guest hanged herself ████████ at her home address on the 24th March 2024.

During the course of the evidence from both family and medical witnesses it became clear that there were no adequate systems in place for providing crisis support to patients over the age of 65. The family were very concerned and very frustrated by the futile attempts they made to secure psychiatric input and support when they could see a rapidly deteriorating picture. There was no explanation as to why individuals in crisis who were 65 or under had access to the crisis service but once a person is over 65 that service is no longer available to them. It is not clear whether access to such services would have altered the outcome but the current structure and services available in my view denied Ms Guest with the opportunity of obtaining specialist assessment support at a much earlier stage. A further concern was that the GP surgery provides patients with the crisis number seemingly without appreciating that this would only be available to those who were 65 or under. Furthermore, the family's evidence was that when they called 101 seeking medical input and support for Ms Guest, they were told they would be referred to the crisis team but as soon as Ms Guest's age was mentioned they halted that process and said that they would not be able to refer her after all because of her age.