A coroner has ruled the chances of a young woman taking an overdose may have been reduced ‘if things had been done differently’.
Much-loved Katie Moorhouse, 20, who had a history of mental health issues and self-harming, died in hospital on December 9, 2016, due to the effects of an overdose of the beta-blocker propranolol.
A Chesterfield coroners’ court inquest heard Ms Moorhouse was prescribed 28 days’ supply of propranolol by a nurse practitioner at her GP practice two days before she died.
This was despite the fact she had overdosed on iron tablets the month before and had a history of overdoses.
The court also heard the community mental health team did not make further contact with Ms Moorhouse after she told a psychologist she was thinking of taking an overdose.
Coroner Peter Nieto recorded a narrative conclusion at the end of the two-day inquest and ruled that Ms Moorhouse, of Dovedale Crescent, Buxton, did not intend to take her own life by taking the propranolol.
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In his narrative conclusion, Mr Nieto said today: “During a consultation on November 29, 2016, Ms Moorhouse told her psychologist that she was thinking of taking an overdose and she presented as lower in mood than usual.
“The psychologist contacted the mental health support service and the community mental health team duty worker to relay her concerns as to Ms Moorhouse’s comments.
“Her understanding was that the concerns would be considered.
“The community mental health team duty worker attempted to contact Ms Moorhouse but did manage to speak to her mother.
“Although the duty worker did not consider that there were any increased risks for Ms Moorhouse, a message was left for the duty worker for the following day to make further contact but for whatever reason this was not done.”
Mr Nieto continued: “Ms Moorhouse had an appointment with the nurse practitioner who had accreditation to prescribe medication at her GP surgery on December 7.
“Ms Moorhouse stated that she was having sleep and anxiety problems.
“She was prescribed up to 28 days’ supply of propranolol for anxiety.
“At the time the nurse practitioner was aware that Ms Moorhouse had taken an overdose of iron tablets on November 3 but was unaware of her lengthy history of self-harm and there was no warning or alert on the GP practice system to this effect.
“The nurse practitioner stated that Ms Moorhouse did not present as suicidal.
“She stated that if she had been aware of the full history she may have still prescribed the propranolol although a lesser quantity.”
Simon Moorhouse found his daughter unresponsive at the family home on December 9.
She was taken to Stepping Hill Hospital in Stockport but sadly passed away just hours later.
Post-mortem tests revealed Ms Moorhouse died of propranolol fatal toxicity.
Mr Nieto said: “Although Ms Moorhouse had clearly taken the propranolol, it cannot be established beyond reasonable doubt that she did this with the intention of ending her own life.”
He pointed to the fact that she did not leave a suicide note.
Mr Nieto added: “While the court cannot state on the balance of probabilities that some form of overdose by Ms Moorhouse in December 9 was preventable, the court does note a number of points at which, if things had been done differently, the chances of overdose at that time may have been lessened.”
He said the information from Ms Moorhouse’s psychologist to the community mental health team ‘was not fully followed up and there was no team discussion of the concern’.
Furthermore, Mr Nieto said, Ms Moorhouse did not have a dedicated mental health care co-ordinator for several months before her death.
He continued: “Despite Ms Moorhouse’s overdose of iron tablets on November 3 and her history of overdoses, she was prescribed 28 days’ supply of propranolol on December 7.”
Mr Nieto added finally: “Had inter-agency infotmation sharing been more effective then all agencies would have had a better appreciation of risks and there could have been a co-ordinated approach to providing support to Ms Moorhouse taking into account a shared understanding of her self-harm risks.”
On the opening day of the inquest, Mr Moorhouse and his wife Jayne questioned why their daughter was not sectioned when she took the overdose of iron tablets on November 3.
Mr Moorhouse added: “She was reluctant to speak to us (about her problems).
"She didn't think we'd understand."