Mother Questions Why Doctors Did Not Inform Her After Daughter Disclosed Suicidal Intentions

The mother of a teenager who informed a doctor of her plans to end her life before subsequently dying by suicide has raised concerns about why medical professionals did not notify her. Issy Phipps, 17, was a student at Hartpury College in Gloucester. She passed away at her residence in Cookham, Berkshire, in April 2023. Despite communicating her intentions to a general practitioner the day prior and speaking with a mental health nurse, no healthcare professional contacted her next of kin, and a referral was never completed. “I can’t understand why they wouldn’t ring next of kin to make her safe,” stated her mother, Sarah Renton. Issy was a gifted singer and had participated in rugby throughout her life, playing for Berkshire, Maidenhead, and Reading. She had also recently earned a gold medal as part of the England Under 18s touch rugby squad. However, she also suffered from depression and had been prescribed an antidepressant medication when she was 16. She was selected for a position at a rugby academy operated through Hartpury College, where she boarded, and was performing well. Nevertheless, she continued to struggle with her mental health, leading a doctor in Gloucester to prescribe a new antidepressant drug, which has been associated with causing suicidal thoughts. Her parents were not informed. On April 28, 2023, Issy attended an emergency general practitioner appointment at Staunton and Corse GP Surgery in Gloucestershire. She told a trainee doctor that she intended to take her own life at home that weekend and mentioned that her parents would be away. The GP referred her to Gloucestershire Health and Care NHS Foundation Trust’s first point of contact centre. A mental health nurse subsequently called and spoke to Issy, who reiterated her plan. The nurse then contacted the county’s crisis resolution and home treatment team, which stated it would be unable to provide assistance, as Issy would be back home and outside their geographical area. Berkshire Healthcare NHS Trust also declined her referral, informing the nurse that it needed to originate from a general practitioner. No one contacted Issy’s parents. “There was a duty of care. I don’t know how anyone could watch a minor walk out the door without knowing 100% she was safe,” Ms Renton said. “She was massively let down.” Issy took her own life the following day. Moments before, she posted old photographs on her family’s WhatsApp group with the message “will always family” and a pink heart emoji. “She loved family,” her mother commented. “She was very likeable, she could talk to anybody. She was warm, funny and very popular.” “I definitely feel like Issy should be here. She was having a crisis. A lot of simple things could have been done better – just ring the family, make them safe. We all need that at our lowest. Someone we love to just be there and say it’s going to be OK. Issy didn’t get that.” Both Gloucestershire and Berkshire health trusts have conducted internal reviews. Gloucestershire Health and Care NHS Foundation Trust stated in a press release: “We have worked with partners in Berkshire to identify what more could and should have been done to keep Issy safe and try to prevent this tragic outcome. We will ensure that learning from both the inquest and our own internal review is embedded into practice, in the hope that we can prevent similar outcomes in the future.” Berkshire Health Trust commented: “We have put in place processes to improve communication in cross-border referrals including ensuring that a conversation between clinicians always takes place where crisis support is requested by someone outside of the county.” Ms Renton hopes that discussing Issy’s story will assist others in the future. “Issy went to a professional to ask for help,” she said. “She knew she wasn’t well yet she still found herself on her own.” “Issy’s is not an isolated story. There are too many. We need to do better. The guidelines are there and make sense, so maybe we just need to enforce them and make sure everybody is getting the same level of care and not falling through the cracks.” “I honestly believe that in a different area, with a different GP, it could have been a very different story.” Alison McCormick, assistant coroner for Berkshire, concluded that: “On the balance of probabilities the lack of notification of Isobelle’s disclosed plan to end her life to her parents made a more than minimal contribution to her death.” If you have been affected by any of the issues raised in this story you can visit BBC Action Line. You can follow BBC Berkshire on Facebook, X (Twitter), or Instagram. Copyright 2024 BBC. All rights reserved. The BBC is not responsible for the content of external sites. Read about our approach to external linking.