"Opportunity missed to review care" - inquest

For 40 years, Anne Rosemary Morgan battled bipolar disorder, recently receiving treatment from colleagues at Prospect Park Hospital in Tilehurst, where she was a member of the clinical staff.
Her marriage to husband Gary had failed, causing her to leave the security of the family home in Upper Bucklebury, the hearing in Newbury on Wednesday, December 4, was told.
On January 31, the 57-year-old mother-of-three hanged herself in the garden of her new home in Beancroft Road, Thatcham. She had left a note.
Despite Mrs Morgan having previously expressed suicidal thoughts during bouts of illness, Berkshire coroner Peter Bedford remarked on a “sea change” in her behaviour during October last year, when she made another apparent attempt on her life.
Then, in December last year, she was prevented from attempting to take her life, later telling doctors that on another occassion she had thought of ending her own life.
Mrs Morgan was transferred from Prospect Park Hospital to Warneford Hospital, Oxford, and was discharged on January 14 this year.
Her brother, former teacher Nicholas John Barton, said he had visited her home on January 31 when she failed to arrive for work, and made the distressing discovery.
The inquest heard from various psychiatrists who treated Mrs Morgan, including Dr Andrew Molodynski, who described a “toxic mixture of severe mental illness and different changes to her social situation”.
He explained the decision to discharge Mrs Morgan from hospital, saying that, although nothing could be done about her social circumstances, her recent bout of illness had apparently responded to treatment and that she was in danger of becoming institutionalised.
The inquest then heard from Marion Cade, a social worker with the community mental health team based in Newbury, who visited Mrs Morgan at home after her hospital discharge.
Each time, she said, Mrs Morgan expressed suicidal thoughts. Then, on one occasion, said Mrs Cade, Mrs Morgan said she had formed a suicide plan.
She added: “She said she didn’t think she would do anything but that she wouldn’t tell me if she did.”
In another development, Mrs Morgan asked for check-up calls from the mental health team to be discontinued.
Mr Bedford asked: “Wouldn’t this have been an opportunity for a psychiatric review?
“It just seems to me that, what was new was that, for the first time in her history, she has harmed herself. This is now someone who has acted on suicidal thoughts, not just expressed them. It just seems to me this is a sea change.
“It does seem to me there could have been opportunities to bring in a senior psychiatrist, or clinician, to review her. No-one knows what would have come of it, or whether it would have changed the tragic outcome, but some significant issues arose with each visit. I acknowledge completely this is with the benefit of hindsight.”
Mrs Cade agreed that, with hindsight, it would have been advisable to make an urgent appointment to have Mrs Morgan’s treatment reviewed.
In a narrative verdict Mr Bedford referred to the “missed opportunity” to escalate Mrs Morgan’s care and concluded that she had intended to take her own life.