Maureen Anne CAMPBELL-SCOTT · Prevention of Future Deaths report

On 18/07/2017, I commenced an investigation into the death of Maureen Anne CAMPBELL-SCOTT. The investigation concluded at the end of the inquest 26th March 2018. The conclusion of the inquest was a narrative conclusion:

Maureen Campbell-Scott suffered fatal injuries when she fell from the ledge of the Exchange Shopping Centre. She died as a result of her own actions, but the evidence does not reveal her intention at the time of the fall.

Maureen Campbell-Scott had suffered for many years from depression and anxiety. She suffered a decline in her mental state in around April 2016. The GP referred her to the mental health services on 29 April 2016. There was a delay in the correct team processing the referral. She was assessed by the older age mental health team in September 2016, but was not considered to meet the criteria for specialist mental health services at that time.

She came under the care of the specialist mental health services in November 2016 following her husband’s contact with Mental Health Direct. She remained under the care of the specialist mental health services until she passed away.

Medication that she had remained stable on for many years, appeared no longer to be working for her. Her medication regime was therefore changed by her consultant psychiatrist. There were some delays in communicating requested medication changes to the GP. Directions provided by the mental health team to the GP, in relation to prescription of mental health medication were not fully complied with. It is not possible to determine whether the poor prescribing and delayed communication contributed to her death.

On the 16 June 2017, Maureen climbed over the wall of the Exchange Shopping Centre car park and lay down on a ledge which was approximately fifty feet high. She had placed a plastic bag over her head. When a member of the public and staff from the shopping centre attempted to help her, she was seen to roll off the ledge. She died as a result of multiple injuries. Her life was pronounced extinct by a paramedic on scene at 20.19 on 16 June 2017.

(1) The GP had sent the referral to the wrong team of the mental health trust. The referral then got lost between the receiving team and the correct team (the older age mental health team). This resulted in a 4 month delay in Maureen Campbell-Scott receiving an assessment.
(2) There were often delays (in excess of 14 days) in the delivery to the GP of clinic letters from the mental health trust. Often, the clinic letters contained requests for the GP to make changes to medication.
(3) The prescribing by the GP did not always follow the direction given by the psychiatric team.
(4) In times of acute mental health crisis, medication if often rapidly changed/supplemented. Mrs Campbell-Scott had 7 changes in her medication regime between 21 November 2016 to 23 February 2017. It is challenging for GPs to be able to ensure rapid and accurate changes when medication changes are directed by the specialist team.
(5) At the time of the Inquest hearing, there had been no joint meeting between the mental health trust and the GP practice to consider the best way forward in terms of referrals to the service; prescribing during times of dynamic medication changes and general communication between the GP and the psychiatrist.
(6) It is accepted that the concerns in this case are unlikely to be restricted to the Fulwell Cross Surgery. If a joint protocol is agreed between the Trust and the Practice, this could be shared more widely with other practices.