‘Opportunities missed’ in care for pregnant Clacton woman who took her life, coroner finds

Joanne Norris with her daughter Lily

Joanne Norris with her daughter Lily - Credit: Archant

Health workers involved in caring for a pregnant woman who took her own life were not made aware of her background of mental health problems.

Joanne Norris was 35 weeks pregnant with her second child when she walked in front of a train at Witham railway station on March 16 last year.

Mrs Norris, from Clacton, texted her husband Jeff minutes before she took her life, saying: “I love you and Lily [the couple’s daughter, aged three at the time] with all my heart. It’s not your fault I am like this.

“I just can’t cope any more. I’m sorry.”

Her baby, already named Jack by the couple, was due on April 21.


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Mrs Norris was declared dead at the scene by paramedics after being hit by the train and consultant pathologist Dr David Rouse noted during a post-mortem examination the cause of death was multiple injuries.

An inquest into her death held at Essex County Coroner’s Court in Chelmsford today heard she died instantly.

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Mrs Norris, 28, was described by her husband, who had been with her for ten years and married for five, as “a beautiful wife and a fantastic mother”.

She had suffered with anxiety since the age of 17 and had a long-term prescription for a drug, Venlafaxine, to manage the condition.

The drug meant she could lead an untroubled life, including working at Tendring Technology College helping children with learning difficulties.

After seeing staff at the East Lynne Medical Centre shortly after becoming pregnant she stopped taking the drug without being offered alternative treatments, and no clear background of her mental health problem was provided to midwives on her initial referral to their care.

The issue arose again in February 2014 when she saw doctors at the centre after telling an out-of-hours GP service she was having panic attacks so severe “normal life was not possible”.

She was given a short-term prescription for Diazepam by Dr Simon Sherwood, who told the inquest the medication was to help with morning sickness, and two weeks later Dr Adekunle Olowu put her back onto Venlafaxine.

Neither doctor nor her midwife Anne Lines thought Mrs Norris was suicidal at any point, though Mrs Lines did twice offer to refer her to a mental health service and contacted the area team on one occasion, the inquest heard.

On the day of her death Mrs Norris twice phoned the mental health crisis team saying she had had thoughts about jumping in front of a train, and agreed to see staff later that afternoon.

However when two workers arrived at her home four hours after the call they were told by Mr Norris she had died.

An investigation by the North Essex Partnership, a mental health trust, said there appears to have been a reliance on self-referral from Mrs Norris.

Coroner Michelle Brown concluded the death was suicide.

Summing up she said: “Opportunities have been missed in respect of the initial referral to the hospital from the GPs’ practice and the lack of adequate recording in the GPs’ notes meant the evidence was insufficient to ascertain whether she stopped taking the drugs of her own accord or because she was advised to do so.

“There is also insufficient evidence to show whether restarting the Venlafaxine contributed to her death, or whether the Diazepam was prescribed for sickness or anxiety.

“However these were clinical decisions made by medical professionals and outside the remit of this inquest.”

The inquest heard the GP practice has changed its procedure to review all new pregnant mothers for possible mental health problems, and had changed the way it shared information.

The court was also told how Colchester Hospital University Foundation NHS Trust, which runs midwifery services in Clacton, had a new IT system which allowed GPs to directly access patient records.

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