Noleen Mary McPHARLANE · Prevention of Future Deaths report

On 24 April 2014, one of my assistant coroners, Richard Ian Brittain, commenced an investigation into the death of Noleen Mary McPharlane, aged 41 years. The investigation concluded at the end of the inquest on 6 August 2014. The determination I made at inquest was that Noleen McPharlane died from the ingestion of an excess of a drug she had purchased on the internet. Her intentions in this are unclear.

Ms McPharlane had had a lot of contact with the mental health services over the course of her adult life. She had diagnoses of unstable personality disorder, depression and obsessive compulsive disorder.

In February 2013, her care was taken over by the personality disorder community team at Highgate Mental Health Centre and remained thus until her death a little over a year later.

1. Ms McPharlane had a long history of overdoses and self inflicted wounds, her last admission to hospital for treatment for the consequent physical injuries being in May 2013. However, in the year following that until her death, the clinical specialist who looked after never once asked her directly if she had thoughts of taking her life.

2. The medical records made clear that Ms McPharlane had a history of buying illicit amitriptyline from the internet and taking this to excess. However, in the last year of her life, her clinical specialist never once asked her if this was ongoing, or advised her about this, or explored the issue with her in any way. He now regards this as unacceptable.

3. The clinical specialist, ████████, by profession a mental health nurse, saw Noleen McPharlane once a fortnight. The sessions were scheduled to last 50 minutes, but frequently only lasted 20 or 30 minutes.

He told me that this was because she did not initiate conversation and responded to questions only briefly. He did not feel he had a good rapport with her.

No other health professional from Highgate Hospital saw her. ████████ did speak to his manager, another clinical specialist (by profession a social worker) about Ms McPharlane, and twice over the year to a psychiatrist. However, there was never any exploration of the possible therapeutic benefit of direct input from an alternative healthcare professional. ████████ now thinks that would have been appropriate.