Coroner calls for lessons to be learned after Norwich woman’s suicide

A coroner yesterday called for lessons to be learned following the death of a Norwich woman who killed herself while suffering from a severe depressive illness.

Krista Thompson, 49, who was born in South Africa, was pronounced dead at home in Parmentergate Court on June 29 last year. A post-mortem examination gave cause of death as hanging.

An inquest into her death yesterday heard Miss Thompson, who moved to the UK in November 2004 to look after her mother Joan, suffered from a severe depressive illness. Her mother died from cancer in 2007.

A significant factor attributed to Miss Thompson's depressive illness was the treatment for the skin cancer she was diagnosed with in 2010 and the resultant scar left on her forehead.

Miss Thompson, who the inquest heard felt her 'life had been taken away' by the scar, took an overdose in January 2011 and was referred to the crisis team at the Norfolk and Suffolk NHS Foundation Trust.

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Between February and June last year she was seen regularly by members of the trust who put in place various care plans, including home visits as part of her treatment. She spent time at Hellesdon Hospital, on the edge of Norwich, initially as an informal patient but was sectioned on March 23 after refusing medication and had six sessions of ECT treatment.

After being discharged from Hellesdon on June 15 a care plan was devised where she received daily visits, but after June 25 this was extended to every two to three days.

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The inquest heard that on June 28 she should have been seen by a member of the team but was not, despite someone trying to visit her home and phone calls being made.

Trust policy was that a note should have been left at the address, a revisit made and family members called within four hours of the attempted visit but this was not done.

It was not until 9.45pm the following day, after attempts had been made to call Miss Thompson that her sister Donna was called. Police were called at 10pm.

Officers forced entry into the property at 11.06pm and found Miss Thompson.

Michael Lozano, patient safety and complaints lead at the Trust, told the inquest a root cause analysis was completed following Miss Thompson's death and recommended a review of current practice.

Changes included the way in which family members were involved in the care and contacted by the trust.

Norfolk Coroner William Armstrong said there were 'significant failings in the care given to Krista which may not have contributed to her death but which nevertheless are disturbing'.

He said 'most alarming' was the lack of any real meaningful action between June 28 and the next day which he said was 'unjustified and unacceptable'.

Mr Armstrong, in a narrative verdict, said: 'Krista Thompson died as a result of suicide as a consequence of hanging herself while suffering from a severe depressive illness, 15 days after being discharged from liability to detention under section three of the Mental Health Act and while subject to section 117 of that act.'

Speaking after the inquest Miss Thompson's sister Donna, on behalf of brother Adam and sister Lyn, said: 'If more prompt action had been taken she could've been alive today.'

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