Samantha Savage-Greene · Prevention of Future Deaths report

On 24.05.18 an investigation was commenced into the death of Samantha Savage-Greene. The investigations concluded on 03.12.18 at an inquest hearing;
Record of Inquest
Section 2
1a) Multiple injuries.
Section 3
On the morning of the 23.05.2018, Samantha Leigh Savage-Greene jumped from a bridge over the M67 motorway, East Hyde.
Section 4
Suicide

About 4 years prior, Samantha suffered an episode of severe anxiety and tried to take her own life by cutting her wrists. She underwent a recovery over 12 months with CMHT. Samantha was then stable.

On 18.05.2018 Samantha showed signs of a recurrence of anxiety.
On 21.05.2018 Samantha went to her GP and was prescribed zopiclone.
On 22.05.2018 Samantha attended A&E at Tameside General Hospital. She was seen by a RAID (Rapid Assessment Intervention & Discharge) team. Samantha was assessed as not needing admission. Samantha was prescribed olanzapine and was to be reviewed by the Home Based Treatment Team. The olanzapine prescription was to be issued by the GP.

The RAID practitioner requested the HBTT (Home Based Treatment Team) to accept Samantha to:

a) monitor her taking her medication;
b) monitor the effects of the medication;
c) monitor for deterioration.

The HBTT declined to accept Samantha on the first and second times of asking. On a third time of asking Samantha was accepted. Samantha was discharged home from A&E.

A HBTT home visit was scheduled for 24.05.2018.

On 23.05.2018, at about 10.35 hrs, Samantha was driving her car over a bridge crossing the M67, when she suddenly stopped her car, got out and jumped over the bridge barrier onto the motorway beneath. Samantha was not struck by any vehicles and her injuries were sustained in the fall.

The MATTER OF CONCERN is that despite the concerns of the RAID practitioner that the HBTT refused to accept Samantha, as she did not fit the protocol for acceptance, on the first two requests. The HBTT was the only means by which Samantha could be monitored other than an admission and satisfy the RAID practitioners concerns. Samantha was accepted by the HBTT on the third time of asking. This appears to be because the person receiving the request was prepared to see Samantha, a person rather than restricted by protocol and by the fact that the RAID practitioner was so concerned about Samantha that she was going to review Samantha within the RAID processes, which was not part of its remit. Without monitoring it would not have been possible to prescribe olanzapine.

There is clearly a lacuna in the provision of supervision and monitoring of patients who are not deemed admissible, voluntarily or by section between the RAID and HBTT services. The RAID practitioner should not have experienced such difficulty in obtaining monitoring for Samantha, a patient who appeared to fall between the protocols of two services.