Mental health care changes after suicide

SIGNIFICANT changes have been made to the way mentally ill people are treated in Suffolk after an Ipswich woman committed suicide within days of being discharged from hospital.

SIGNIFICANT changes have been made to the way mentally ill people are treated in Suffolk after an Ipswich woman committed suicide within days of being discharged from hospital.

The body of Nicola Duncan was found in her VW Golf at Walberswick on May 30, 2007, only a fortnight after doctors had released her from a seven-week spell at St Clement's in Ipswich where she had been receiving psychiatric treatment.

The 34-year-old, of Lancaster Road, killed herself by taping a length of pipe between the car's exhaust and its front window, shortly after penning a suicide note.

At an inquest at Ipswich Crown Court yesterday, Suffolk Mental Health Partnership Trust (SMHPT) said a raft of improvements had been implemented following Miss Duncan's death.


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Bosses claimed an investigation had prompted the changes, which included greater access to specialist treatments, better information for patients' families and a formal referral process.

Today, Miss Duncan's family welcomed the overhaul.

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In a statement, they said: “What we wish to see resulting from the tragedy of Nicola's death are improvements in the treatment of the mentally ill in Suffolk.

“Lessons must be learned so that other families are not put through the same traumas that we have suffered.

“We have lost a loved one in circumstances which were distressing in the extreme and we owe it to Nicola that if any good at all can come from this tragedy it should be to the benefit of other unfortunate victims of mental illness.

“We will miss her everyday for the rest of our lives but we know now she has found peace from the mental torment she suffered.”

The inquest heard how Newcastle-born Miss Duncan had been forced to wait for five weeks before receiving Electro Convulsive Therapy (ECT), which, her parents claimed, briefly “brought our daughter back”.

However, she relapsed soon after, with medics believing her confusion had been induced by a relationship she had embarked upon with another patient.

Miss Duncan's mother, Sonia Duncan, told the inquest that the relationship had been “highly unsuitable”, and she also said her daughter had written a 71-page document, which contained details on how she planned to commit suicide.

“She learnt how to commit suicide and the manner in which she did it from fellow patients,” said Mrs Duncan. “If anybody had looked at that book they would have known how seriously disturbed Nicola was.”

Dr Tim Webb, who chaired the investigation panel, said the trust had learnt from Miss Duncan's death.

“I certainly hope these lessons are being put into practice now,” he said. “This is one of numerous examples where we can do something simple which will make a big impact.”

The coroner, Dr Peter Dean, recorded a verdict of suicide, which he said took place on or around May 22, the day Miss Duncan was last seen.

He said: “There were a lot of people who were trying to do what they could for her, but they faced enormous difficulties. Her stay on the ward was prolonged by her difficulty in accessing ECT as soon as the need was recognised.

“With the benefits came the risk of relapse which may not have been fully appreciated at the time. One can see why that may have been misinterpreted and why a relapse might not have been recognised.”

Last night, SMHPT spokesman Nicola Brown said: “As a result of the inquiry we carried out into Nicola's care and treatment, we have greatly improved the accessibility and funding for ECT treatment and are enhancing the information we give to patients and their families. The inquiry highlighted areas of which we were previously unaware, including a need to formalise the referral procedure for ECT, and these have also being addressed.

"In addition, and although our medical director Dr Tim Webb concluded that 'talking therapies' would not have been significantly beneficial in Nicola's case, we are increasing the availability of psychological therapies on the wards. We are pleased that the current Suffolk PCT has given us the resource to recruit a lead psychologist to head this up in our inpatient areas and this post will be re-advertised shortly. Suffolk PCT has also listened to our recommendations in improving access to psychological therapies in primary care settings, such as GP surgeries, too and we are recruiting to new community posts as well.”

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