Content warning: This article makes reference to suicide.

The cause for the investigation involves the experience of a woman with a history of depression and anxiety. Her mental health had been managed through medication after a hospital admission in 2019 due to a suicide attempt. She was considered to be experiencing depression and displaying symptoms of a first episode of psychosis after a clinical assessment.

After nearly a month-long hospitalisation under the Mental Health Act, she was discharged and put into the care of a local community mental health team. However, this team failed to refer her onto the clinical pathway specifically for a first episode of psychosis despite meeting the criteria.

The NHS England clinical standards body, the National Institute for Health and Care Excellence (NICE), published guidance in 2014 that stressed the importance of early intervention for the first episode of psychosis and prominently highlighted the need for services to be accessible to everyone, irrespective of age.

Yet, a significant error of judgement had occurred. ‘The Independent’ has seen the details of an internal NHS Trust investigation which has discovered that her clinicians incorrectly believed she was far too old for specialist NHS psychosis services.

A national investigation into a series of missed opportunities

Subsequently, eight months after her first hospital admission, the 56-year-old woman required another inpatient hospital stay due to another suicide attempt but was promptly discharged a month later. She was then initially seen by a crisis team before being transferred back to the care of her community mental health team.

While in their care, another error occurred, detailed in the NHS Trust’s internal report, it was found that during the first Covid-19 pandemic lockdown in March 2020, she was not contacted for three months, far short of the recommended weekly check-ins. Though more frequent contact did resume, five days after her last telephone review with a consultant psychiatrist, it was found that she had lost her life to suicide.

To understand the clinical judgements, in this case, the HSIB investigation is seeking to explore the process of the initial and ongoing risk of harm assessments, as well as looking into how community mental health teams undertake risk assessments and how specific pathways of care are allocated.

Should menopause be considered in risk assessments?

Another aspect to be examined in the HSIB investigation will be the way in which mental health services consider menopause when assessing women with new-onset mental health conditions and how this might inform risk assessments.

Research has shown that a reduction or fluctuation in oestrogen, just as peri- and during menopause, has the potential to trigger or aggravate mental health problems, including enhancing the risk of a first episode of psychosis. This is because the sex hormone has important neuroprotective functions, which are reduced with oestrogen decline or instability.


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