A mental health trust has already adopted a seven-point plan of improvements to procedures following the tragic death of a 22-year-old woman from Billinghay.
An inquest on Friday at Boston Coroners’ Court into the death of Sophie Rebecca Webster, formerly of Shire Close in the village, recorded a verdict of suicide after she took her own life at a bridge on June 17, 2015, at Holt Lane, in Mareham le Fen.
It was revealed she had left a note and coroner Paul Cooper said it was clear to him that Miss Webster knew what she was doing.
Just 12 days before, she had been deemed well enough to leave Pilgrim Hospital in Boston having been admitted a week before suffering from a ‘drug induced psychosis’.
After first being treated at Lincoln Hospital she was admitted to be psychologically assessed at Boston two days later.
She told medical staff and her mother Gina Webster, of Billinghay, that she had been experimenting with LSD and ketamine as well as smoking cannabis. On first being admitted to hospital she had become agitated and upset, telling her mother: “You need to let me go and know what I need to do.”
She also told consultant psychiatrist Dr Mahesh Nachnani and her mother that she heard voices and was observed to be having hallucinations, the inquest was told.
Dr Nachnani added that she was distressed, tearful and wanted to die and at first refused her medication. He said she first started taking speed around the age of 13.
Having been prescribed anti-depressants by her GP and taking LSD she said suicidal thoughts had got worse, but she improved after changing medication, said Dr Nachnani.
Her mother expressed her concerns at being excluded from decisions at Sophie’s request. Her family felt they could have offered an insight that Sophie was still hearing voices but were not even told of Sophie’s release, the inquest was told.
Mrs Webster said her daughter had lived at home, working for construction firm Taylor Pearson of Coningsby and studying psychology at college.
She had questioned her daughter after her behaviour became out of character and said: “I would ask her what drugs she was taking and she would say nothing, just a bit of weed.” But about her birthday on December 4, 2014, an argument escalated and from then on tensions were high ‘like treading on eggshells’, she said.
Mrs Webster saw her daughter a few days after her release. “She was withdrawn, pale, no sparkle in her eyes. I do not think she was taking her medication,” she said.
The inquest was told following her release, the crisis team from the Lincolnshire Partnership Foundation Trust (the county’s mental health trust) struggled to contact Miss Webster by phone. She was living with her boyfriend, Daniel Gayton at Mareham le Fen. Eventually they did get in touch and she told them she had just broken up with her boyfriend and had started smoking cannabis again.
Gareth Price from the health trust said an investigation produced seven recommendations which have been implemented including regular staff retraining on recognising suicidal behaviour, and information from family and carers can now be more easily passed on without breaching confidence. Information would be better shared among staff and the crisis team will be more proactive getting in touch with discharged patients using pre-scheduled appointments.