A GP knew a teenage girl’s detailed plan to take her own life but did not tell her parents, it has emerged.
Isobelle Phipps was just 17 when she visited a doctor and outlined her suicide plan.
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The trainee GP did not tell the teen’s family but did make a referral to a mental health crisis team, according to an interview with Isobelle’s mum in the The Sunday Times.
A “misunderstanding” between NHS hospitals and mental health specialists meant the referral was rejected and nobody warned Isobelle’s family.
She was found dead the next evening, on Saturday, April 29, 2023, at her family home in Cookham, Berkshire.
Her mum, Sarah Renton – a nurse – is now urging any GPs in a similar situation to inform the parents of a child who appears at risk of harming themselves.
Isobelle, known as Issy, had booked an emergency GP appointment the day before her death.
While she was at the appointment, she revealed a detailed plan of how she would take her own life.
She also collected a prescription for antidepressants on the same day.
Her GP was in Gloucestershire and close to her boarding school Hartpury College, where she loved to play rugby and was studying for A-levels in PE, English and Psychology.
Issy’s family travelled to Wales to watch a rugby match on the Saturday morning, while she went to Twickenham to watch the Six Nations.
She was pronounced dead at her family home later that evening.
It emerged that the Gloucestershire-based traniee doctor contacted Isobelle again later on the Friday after her morning appointment.
GP Dr Mostapha Hassan, working at Staunton and Corse, had asked for advice from his supervisor, Dr Mungo Chambers.
The advice did not include telling her family.
An inquest into Isobelle’s death heard Dr Hassan explain why he did not take additional steps to attempt to contact Issy’s family.
Isobelle’s case is unfortunately another tragic example of how different arms of the NHS do not properly integrate with each other.
Ben Davey
He said: “Something in her body language made me feel she wasn’t going to act on it,” according to Dean Wilson, the law firm representing the family, on their website.
A referral was made to a crisis team at Gloucestershire Health and Care NHS Foundation Trust.
WHERE TO GET HELP YOU NEED
IF you are ever worried that someone’s life is in immediate danger, call 999 or go directly to the emergency services.
For anyone in crisis, struggling to cope or needing immediate help, use the Shout Crisis text line (text 85258) or The Samaritans (call 116 123) – which are both available 24/7, 365 days a year.
CALM offer a confidential helpline (0800 585858) and livechat, both available from 5pm to midnight.
Visit nhs.uk/mental-health/ to find NHS mental health support near you, and how to self-refer for talking therapies, such as CBT and counselling for mental health conditions including depression, anxiety, panic, OCD and more.
Visit the Movember website for more advice on men’s health and recommended support groups, organisations and charities.
Movember Conversations is an online tool that helps you practise difficult conversations with pretend scenarios
The team contacted Issy, who informed them she would be returning home to Berkshire for the weekend and of her plans to end her life.
The crisis group contacted colleagues in Berkshire, where the teenager was staying for the weekend.
Berkshire Healthcare NHS Foundation Trust would reportedly not accept the urgent referral as it had to come from a GP and the teen was not registered with a GP in Berkshire.
At the inquest held across October 16 and 17, this was called a “misunderstanding” by an official at Berkshire Hospital who said it should have accepted the referral.
As a result, no healthcare professionals reached out to Issy’s family.
Later that evening, Issy sent messages to her family and friends.
Her parents attempted to contact her, but did not receive a response to their calls or texts.
Issy’s parents asked a family friend to visit the house, who sadly found Issy deceased in the garage at the family’s home.
Emergency services attended the scene and despite attempts to perform CPR, Issy was pronounced dead at 11:51pm.
LACK OF CARE
Coroner Alison McCormick said at the conclusion of the inquest: “If Issy’s parents had been told of Issy’s plan on April 28, 2023, they would probably have been able to take swift steps to ensure that Issy was not home alone”.
Isobelle’s mother said: “As a nurse, I feel there was an absolute lack of duty of care shown to Issy”.
Ben Davey from Dean Wilson Solicitors added: “Isobelle’s case is unfortunately another tragic example of how different arms of the NHS do not properly integrate with each other.
The Berkshire Hospital Trust said it now has processes in place to “improve communication in cross-border referrals”.
Meanwhile, the Gloucester Health and Care NHS Foundation Trust said work is ongoing to “prevent similar outcomes in the future”.
