'Ineffective' medication factor in woman's suicide

Suffolk coroner Nigel Parsley ruled Amy Butcher's death could have been prevented

A coroner said "action should be taken" after a woman took her own life days after being prescribed medication which failed to manage her anxiety.

Amy Butcher was declared dead inside a premises in Suffolk on 14 May 2023, just under a week after writing a note saying she intended to take her own life.

At the time she was being treated by mental health services and after been admitted to A&E on 10 May 2024 in a "heightened anxiety crisis" was given Lorazepam.

It proved "very effective" but she was refused a prescription in favour of "ineffective" medication, which coroner Nigel Parsley ruled to be a contributing factor in her death.

Mr Parsley called on MP Wes Streeting to look into taking action to "prevent future deaths"

According to Mr Parsley, Ms Butcher had made "repeated requests" for a prescription of Lorazepam to NHS 111, her mental health crisis team and GP, but was refused.

Then, on the evening before her death, Ms Butcher became particularly distressed for hours before eventually calming down and falling asleep.

Toxicology reports confirmed at some point before her death she had taken her prescribed medication but in the early hours awoke before taking her own life.

An investigation into her death was launched five days later, which concluded her medication had not "alleviated her heightened anxiety crisis".

It determined she died after a deterioration in her mental health which was exacerbated by an ineffective PRN medication prescription.

Mr Parsley said: "Had Amy had access to Lorazepam as a PRN medication on the evening it is more likely than not that her death would not have occurred."

'Too many chiefs'

In a Prevention of Future Deaths report, he said he had identified a "muddled and unclear system" for the prescription of medication to those in Ms Butcher’s situation.

During his investigation Ms Butcher’s GP noted the system for prescribing mental health medication was "confusing" and there were "too many chiefs".

It was also said that a decision had been by the Mental Health Multi-Disciplinary Team (MDT) to not prescribe Ms Butcher Lorazepam "in any event".

She had used a micro dose of hallucinogenic mushrooms to alleviate her symptoms and the team was concerned about how the two drugs would interact.

The MDT also said she had previously disposed of medications prescribed to her and was also of "higher risk of prescription misuse".

Mr Parsley, however, ruled a "lack of knowledge" prevented a realistic opportunity for the MDT to consider if Lorazepam should have been prescribed to Ms Butcher.

Mr Parsley has now submitted his Prevent of Future Deaths report to Secretary of State for Health and Social Care, Wes Streeting, and urged him to look into the death.

He said: "In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action."

Anthony Deery, the chief nurse at Norfolk and Suffolk NHS Foundation Trust, said “We are very sorry for the distress Amy’s tragic loss has caused and would like to offer our sincere condolences to her family.

"We are now carefully considering the coroner's Prevention of Future Deaths report so that we are able to make the changes needed to make sure our services are safer, kinder and better in the future."