Medication delay contributed to death - report

Bency Joseph first attended Broomfield Hospital to seek help and was put under the watch of mental health professionals

A delay in prescribing and administering anti-psychotic medication contributed to the death of a woman, a coroner's report said.

Bency Joseph died at home in Essex on 27 May last year, days after she first went to a hospital's accident and emergency department to seek help with her mental health.

In a prevention of future deaths report, coroner Sonia Hayes said she had written to the local NHS mental health trust, which was caring for her, with concerns including delays responding to Ms Joseph's rapidly deteriorating mental state.

The trust said it was "taking action to ensure learning" from this "tragic incident".

The report said Ms Joseph attended Broomfield Hospital on 24 May with acute psychosis.

She was assessed by a mental health team a day later and referred to the Home Treatment Team and the First Episode Psychosis Team.

Medication was prescribed and administered at the hospital on the same day and she was discharged under the care of the Home Treatment Team.

On 26 May, the team's consultant psychiatrist found she had deteriorated and prescribed urgent medication to be provided on the same day, but this did not happen.

The report said the inquest concluded she died from a "traumatic head injury" after a "fall from height", but said a "delay in the provision of antipsychotic and anxiolytic medications" contributed to her death during a severe psychotic episode.

It said Ms Joseph did not have the capacity to decide to take her own life.

Ms Hayes said: "It is unclear if the urgent prescription was received and processed.

"The family's concerns and attempts to escalate the failure to provide the medication were not actioned by the trust, and the death occurred in the early morning of 27 May as the family were making arrangements to take her back to accident and emergency due to the omission to provide medication and further deterioration."

The coroner said an investigation by the Essex Partnership University NHS Foundation Trust (EPUT) did not inform or involve the trust's senior pharmacist, who was unaware of the death, or Ms Joseph's family, who had tried to contact the trust on 26 May to raise an alert.

"In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action," she said.

EPUT said it would "respond to the coroner in due course".

"We are committed to providing the best patient care and are taking action to ensure learning from this tragic incident is shared and firmly embedded across the trust to drive forward improvement," a spokesman said.