Coroner Identifies ‘Ineffective’ Medication as Contributing Factor in Woman’s Suicide

A coroner has stated that “action should be taken” following the suicide of a woman, which occurred days after she received medication that did not alleviate her anxiety. Amy Butcher was pronounced deceased at a location in Suffolk on May 14, 2023. This was less than a week after she had composed a note indicating her intention to end her life. At that period, Ms. Butcher was receiving care from mental health services. She had been admitted to A&E on May 10, 2024, experiencing a “heightened anxiety crisis,” and was administered Lorazepam. This medication was found to be “very effective.” However, she was denied a prescription for it, receiving “ineffective” medication instead. Coroner Nigel Parsley determined this refusal to be a contributing factor in her fatality. Mr. Parsley indicated that Ms. Butcher had submitted “repeated requests” for a Lorazepam prescription to NHS 111, her mental health crisis team, and her general practitioner, but these requests were declined. Subsequently, on the evening preceding her death, Ms. Butcher experienced significant distress for several hours before ultimately becoming calm and falling asleep. Toxicology reports verified that she had consumed her prescribed medication at some point prior to her death, but awoke in the early hours before ending her life. An inquiry into her death commenced five days later. This inquiry concluded that her medication had not “alleviated her heightened anxiety crisis.” The investigation established that her death followed a decline in her mental health, which was worsened by an ineffective PRN medication prescription. Mr. Parsley commented: “Had Amy had access to Lorazepam as a PRN medication on the evening it is more likely than not that her death would not have occurred.” In a Prevention of Future Deaths report, he stated that he had identified a “muddled and unclear system” concerning the prescription of medication for individuals in Ms. Butcher’s circumstances. During the course of his investigation, Ms. Butcher’s general practitioner observed that the system for prescribing mental health medication was “confusing” and characterized by “too many chiefs.” It was also reported that the Mental Health Multi-Disciplinary Team (MDT) had made a decision not to prescribe Ms. Butcher Lorazepam “in any event.” She had utilized a micro dose of hallucinogenic mushrooms to mitigate her symptoms, and the team harbored concerns regarding potential interactions between the two substances. The MDT further stated that she had previously discarded medications prescribed to her and was considered to be at a “higher risk of prescription misuse.” Nevertheless, Mr. Parsley determined that a “lack of knowledge” precluded a realistic chance for the MDT to evaluate whether Lorazepam should have been prescribed to Ms. Butcher. Mr. Parsley has now submitted his Prevention of Future Deaths report to Wes Streeting, the Secretary of State for Health and Social Care, and has implored him to investigate the death. He stated: “In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.” Anthony Deery, the chief nurse at Norfolk and Suffolk NHS Foundation Trust, commented: “We are very sorry for the distress Amy’s tragic loss has caused and would like to offer our sincere condolences to her family.” He added: “We are now carefully considering the coroner’s Prevention of Future Deaths report so that we are able to make the changes needed to make sure our services are safer, kinder and better in the future.” Information regarding Suffolk news is available on BBC Sounds, Facebook, Instagram and X. Copyright 2024 BBC. All rights reserved. The BBC is not responsible for the content of external sites. Read about our approach to external linking.