Mother thought to have died from morphine overdose waited 12 days for mental health help

A motorist has been banned after being caught drink-driving. Picture: James Bass

A motorist has been banned after being caught drink-driving. Picture: James Bass - Credit: James Bass

A woman who may have died from a morphine overdose had to wait 12 days for a mental health assessment after concerns were raised, an inquest heard.

Karen Lee, 51, of Lyndhurst Road, Lowestoft, underwent knee replacement surgery at the James Paget University Hospital (JPH), in Gorleston, in December 2014.

She had been admitted a week earlier suffering from chronic pain.

The mother-of-three was found dead on New Year's Day 2015 and the medical cause of death is believed to be the excessive ingestion of prescribed morphine.

On the second day of a three day inquest, Greater Suffolk coroner Peter Dean heard that Mrs Lee was admitted to the orthopaedic Ward 7 at the JPH on December 14, 2014.

Sister Caroline Butler, who works on the ward, contacted the mental health referral team on December 18, 2014, as she was concerned Mrs Lee may have bipolar disorder, and expected an assessment to be made within 72 hours.

It was not until 12 days later, on the day of her discharge on December 30, that she was seen by someone.

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Nicholas Michael, representing the Norfolk and Suffolk Foundation Trust, of which the mental health referral service is a part, said that the incorrect form was used and also sent to the wrong location.

A nurse from the orthopaedic ward contacted the service on December 23 to find out when the referral would be taking place and then it became clear the form had gone to the wrong place.

Susan Stolworthy, who works for the mental health referral service, said: 'As we had the liaison nurse in post at the Paget it makes sense for them to go in and see the patient.'

Alex Jamieson, a barrister representing the family, said: 'This case has fallen between the gaps because no contact was made. If not remedied it could easily happen again.'

Another issue looked at by the coroner was the fact that the discharge form was not sent to Mrs Lee's GP until January 2, 2015, when it should usually be sent within 24 hours. This was due to a member of admin staff on the ward being off.

Dr Dean asked: 'Given that so much was atypical about Karen's stay, and the expectation that she would need a discharge letter for her GP, would it not have been helpful to have faxed the letter to the GP when she left, just to touch base?'

Ms Butler said all patients were given a copy of their discharge forms to take home and copies were kept on the ward so they could be referred to immediately if inquiries were made by a relative or GP.

Jacques Howell, a solicitor representing the JPH, noted that the hospital had now moved to an email system. The inquest ends today.