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Senior Coroner Finds Risk Of Future Deaths Due To University Of Bristol Student Health Service Not Following Prescribing Guidelines

Concerns Set Out In Report Following the Death of Natasha Abrahart


Andrew Hewitt, Press Officer | 0114 274 4255

A senior coroner has ordered health services, including the University of Bristol’s GP practice, to explain what action they are going to take to prevent future deaths following the suicide of a student.

Maria Voisin has issued a ‘Preventing Future Deaths’ report, raising concerns that those involved in the care of the Natasha Abrahart did not follow national and local health service guidelines by arranging a follow up appointment within seven days when they prescribed the 20-year-old antidepressants.

The body of the University of Bristol student Natasha was found in her flat in the city on 30 April, 2018.

If guidelines issued by both the National Institute for Health and Care Excellence (NICE) and the Bristol, North Somerset and South Gloucestershire NHS Clinical Commissioning Group had been followed, Natasha, originally from Nottingham, would have been seen by a doctor no later than 27 April, 2018. 

An inquest earlier this month concluded that a series of serious failures by mental health services amounting to neglect contributed to the death of Natasha, a second year physics student.

Ms Voisin, senior coroner for Avon, has written to the University of Bristol’s Student Health Service, Avon and Wiltshire Mental Health Partnership NHS Trust, Health Secretary Matt Hancock and fellow MP and  Minister for Suicide Prevention, Jackie Doyle-Price, raising concern that future deaths may arise a result of failures by doctors to follow guidance issued by NICE.

The coroner has given the quartet until 17 July to reply stating what action they will take to prevent a repeat of Natasha’s death.

Expert Opinion
“It is a matter of significant concern that the usual practice of GPs within the University of Bristol’s Student Health Service appears to breach the guidance issued by NICE and others regarding the prescription of antidepressants to young people at risk of suicide.

"The guidance has been developed for good reason and should be at the forefront of GPs’ minds when caring for this very vulnerable group. This is particularly true for GPs in the Student Health Service given the alarmingly high number of students enrolled at the University of Bristol who have tragically taken their own lives in recent years.”
Gus Silverman, Associate Solicitor

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The inquest into Natasha’s death was told that in early March 2018 a trainee psychiatrist gave her a seven day supply of the antidepressant Sertraline and told her to make a follow up appointment with her GP for 14 days’ time.

Dr Laurence Mynors-Wallis, an independent senior consultant psychiatrist, instructed by Ms Voisin, to review Natasha’s treatment told the hearing that this plan was “inadequate”.  The expert also told the court that a follow up appointment with a doctor is important to check whether the patient is taking the medication, whether they have experienced any side effects, and to monitor their risk of suicide.

On 20 April 2018, Natasha was seen by a doctor at the University of Bristol’s Student Health Service, who noted that she had run out of medication following the one week’s supply issued to her at the beginning of March. They issued Natasha with a 28 day prescription; however, no arrangements were made for a seven day follow up as per the NICE and local CCG guidance.

The inquest was told by a University of Bristol doctor that the “usual practice” of all GPs at the Student Health Service was to make follow-up appointments two weeks after prescribing anti-depressants.

Dr Joanne Mobbs, the Deputy Director of the Student Health Service, told the inquest “I can't be certain that we are meeting guidelines but I'm aware of the guidelines”.

She also said that it would be "extremely challenging" for the University’s GPs to comply with the guidance “with the available resources and the competing demands for other issues”. 

Earlier the inquest had heard that the Student Health Service was partly reliant on the University for its funding.  The University’s most recent Annual Report indicates that in 2017 it recorded an income surplus of £47.2 million.

Natasha’s parents Robert and Margaret Abrahart said:  “If the University’s Student Health Service had followed the guidance like it was supposed to then Natasha would have seen a doctor three days before her death. 

“We will never know what difference this would have made but at the very least it would have given her an opportunity to have a conversation about how she was feeling with someone who was medically qualified.

“As a family we call on the University of Bristol to make sure that it’s Student Health Service has the resources it needs to properly support students who are at risk of suicide.”

Expert Opinion
“If the Deputy Director of the Student Health Service is correct that the Student Health Service is insufficiently resourced to provide the recommended one week follow up appointments then one obvious solution would be for the University to increase its financial support to the Service.”
Gus Silverman, Associate Solicitor

Anita Sharma, of the charity INQUEST which has been supporting the family said: “What could be of higher priority to a student health service and a University than properly monitoring the suicide risk of vulnerable students? Particularly after numerous previous self-inflicted deaths at Bristol University. The Coroner’s concerns must be addressed urgently to ensure the same failings do not continue nationally.”