Inquest told of ‘sub-optimal’ assessment on day Gaia Pope-Sutherland disappeared
An emergency services clinician should have organised a face-to-face mental health assessment for teenager Gaia Pope-Sutherland on the day she disappeared, an inquest has heard.
The clinician spoke to the 19-year-old’s mother just 90 minutes before she ran away from her aunt’s home in Swanage, Dorset, on the afternoon of November 7 2017.
Miss Pope-Sutherland (pictured) was soon reported missing by her family and Dorset Police launched a search operation involving the Coastguard, helicopters and volunteers to find her.
She was found 11 days later in dense undergrowth between Dancing Ledge and Anvil Point near the Swanage coastal footpath having died of hypothermia.
The clinician, who worked for the South West Ambulance Service NHS Foundation Trust, had phoned Kim Pope after her daughter had made a 999 call.
Dorset Coroner’s Court heard the ambulance trust carried out a review of the two calls and concluded the former was handled appropriately but the latter was found to be “non-compliant”.
The jury heard Miss Pope-Sutherland dialling 999 at 1.26pm and speaking to the operator but quickly giving the phone to her mother.
The conversation lasted eight minutes with Ms Pope detailing her daughter’s recent medical history.
It resulted in a clinician phoning Ms Pope at 2.11pm and speaking for about seven minutes with her about her daughter, who by now was with her aunt at her home in Swanage.
The trust’s review found the clinician used “leading questions” to confirm Miss Pope-Sutherland was safe, which was “sub-optimal”.
“It seems clear the clinician and the patient’s mother were both assured the patient did not require ambulance attendance at the time of this call,” the review found.
“No attempt is made by the clinician to contact the patient thus gaining a first-hand account of her current predicament or presentation.
“Best practice is always to seek first party contact to confirm the details of any call and to explore symptoms and clinical need.
“It does appear within this call that the patient’s mother and the clinician were assured that the patient would be attending both the GP and the police station later in the day and this offered some level of reassurance to the clinician triaging the call.
“The clinician closed the call with ‘no response’ despite a detailed and significant history of mental illness and having previously been subject of a Mental Health Act assessment.
“This patient presented an increased risk to themselves and may well have benefited from a face-to-face assessment.”
The clinician no longer worked at the trust “so no further action is possible locally based on this audit”.
The court also heard evidence from consultant psychiatrist Dr Francesca Denman, who had reviewed Miss Pope-Sutherland’s care.
Dr Denman said in her opinion when the college student was detained under the Mental Health Act in February 2017 she was suffering a postictal psychosis after a severe epileptic seizure.
She also thought it was likely she was having a second postictal psychosis when assessed in hospital the following October.
Answering questions from Rachael Griffin, senior coroner for Dorset, Dr Denman agreed there were “opportunities lost” when the teenager was discharged from hospital without mental health support.
“You can’t say what would have happened and all you can say is that it could have made a difference because it could have opened up that opportunity between October 22 and November 7 to have had regular contact with the mental health team and opened up access with the mental health team and her medication to be reviewed,” the coroner said.
“That could have prevented the events of November 7?” Ms Griffin asked.
Dr Denman replied: “It could have done.”
The expert witness said it was clear from the 999 call that Miss Pope-Sutherland was hallucinating on the day she disappeared, and her mental health was deteriorating.
“From what I know she was in a psychotic state, on the balance of probabilities,” she said.
“I am sure that the contributory inputs were not taking her medication, being in an acute situational crisis and having had a fit.
“Whether it is one or all of those I can’t tell you and maybe or maybe not cannabis use, I don’t know.”
The hearing continues.
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