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Investigation and inquest
On 30th July 2020 I commenced an investigation into the death of Trinder Kaur Birdi, 34 years old. The investigation concluded at the end of the inquest on 17th November 2020. The conclusion of the inquest was a narrative conclusion:
Trinder Birdi had a history of depression and personality disorder. She presented with low mood to her general practitioners from the 16th January 2020. On the 29th January 2020 she presented to her general practitioner and reported having taken two paracetamol overdoses in the past two days. Her general practitioner assessed her as high risk of suicide and referred her for an urgent psychiatric assessment in A & E. Ms Birdi was seen by a psychiatric nurse on the same day who reduced the risk of suicide to low. Ms Birdi reported to the nurse that she no longer wished to harm herself. A non-urgent referral was made to the Community Mental Health Team. On the 12th February 2020 Ms Birdi was taken to hospital in acute liver failure. Maximum medical therapy was provided but she did not recover. She passed away from the likely effect of drug toxicity (self-administered). She was not seen by the Community Mental Health Team following the non-urgent referral on the 29th January 2020.
Circumstances of the death
See narrative conclusion above.
The published report provides this section by reference to another part of the report.
Coroner’s concerns
The general practitioner who had known Ms Birdi over a number of years and had seen her for multiple mental health consultations had raised concerns with the A & E psychiatric team that Ms Birdi was at a high risk of suicide. The GP considered that Ms Birdi required an urgent psychiatric assessment and that Ms Birdi was at a high risk of taking a further overdose with a higher number of tablets. Following assessment, the same day, by a psychiatric liaison nurse who had never met the deceased before, the risk to self was reduced to low. The risk was lowered from high to low, without any consultation with the general practitioner or second opinion sought and documented from a fellow psychiatric professional.
It is concerning that the risk to self can be downgraded by a member of staff, new to the patient, following referral from a doctor who knows the patient well. There were no safeguards in place for this circumstance, such as a discussion with the referring general practitioner, second opinion from a fellow psychiatric clinician or assessment by a psychiatric doctor.
