Nigel Parsley, the senior coroner for Suffolk, has voiced concerns about medications that increase suicidal behavior and the pressures on mental health services. His comments follow the death of Gemima Christodoulou-Peace, a 25-year-old who passed away in Ipswich in July 2023 after battling mental health issues.
In a Prevention of Future Deaths Report, Mr. Parsley highlighted the challenges clinicians face when checking medication side effects and the difficulties in accessing urgent mental health care.
Medication Concerns and Mental Health Pressures
Mr. Parsley’s report was directed to Wes Streeting, the Secretary of State for Health and Social Care. Streeting acknowledged the issues and stated that the government is working to fix a “broken system.”
During Ms. Christodoulou-Peace’s inquest, Mr. Parsley noted that there was insufficient evidence to prove she intended to take her own life. He cited the “impulsivity associated with her diagnosed mental illness” as a factor. Although she had previously taken medication known to increase suicidal behavior, it was unclear when she last took it, and none was found in her system at the time of her death.
Struggles with Mental Health Services
Ms. Christodoulou-Peace first reported a decline in her mental health in March 2023 and requested to resume her previous medication. However, her GP needed input from a prescribing mental health practitioner, so a referral was made, but she did not receive it.
Despite reporting her low mood several times, she declined crisis support after an urgent referral to mental health services. She preferred a medication review with the mental health team she had seen previously.
A risk assessment deemed her at “moderate” risk, with a target response time of two to four weeks. However, by the time of her death, she had not been seen by a mental health practitioner who could prescribe medication.
Clinicians testified that, ideally, resources would allow for “much more timely investigations.” Her treatment assessment was scheduled for August 8, 2023, 14 days after her death.
Challenges in Identifying Medication Side Effects
Mr. Parsley expressed concern that clinicians must independently review each prescription medication to identify any risk of increasing suicidal behavior. He noted that for some medications, this side effect is “very rare,” making it unlikely for clinicians to be aware of all such risks.
He emphasized the need for a single reference point for clinicians to easily check if a prescribed medication is known to increase suicidal behavior.
Need for Improved Patient Safety
Another concern was that the Norfolk and Suffolk NHS Foundation Trust only recorded a limited number of patient calls. Mr. Parsley stated that this could impact treatment if different clinicians handled a patient’s case without easily reviewing previous interactions. He suggested that increased accessibility to recordings would “improve patient safety.”
Government Response
A Department of Health and Social Care spokesperson extended their “deepest sympathies” to Ms. Christodoulou-Peace’s family and friends. They emphasized the importance of learning from every prevention of future deaths report and assured that the department would consider Mr. Parsley’s report carefully.
“People with mental health issues are not getting the support or care they deserve, which is why we will fix the broken system to ensure we give mental health the same attention and focus as physical health,” the spokesperson said.
The Norfolk and Suffolk NHS Foundation Trust has been approached for comment.
