On the morning of February 17th last year, 19-year-old Eleanor Lomax, known as Ellie (top), was found in her bedroom by her mother at their home in Barnsley, South Yorkshire.
Laura McClure, a mental health nurse from CAMHS, said that she had first met Ellie in April 2018, when Ellie had been referred to her following a suicide attempt. Ellie was diagnosed with depression and anxiety, and saw Mrs McClure for regular interpersonal therapy sessions.
Mrs McClure said that, during their time together, she did not notice a marked improvement in Ellie’s depressive symptoms and she told the court that she felt “disappointed in herself” that Ellie’s symptoms had not lifted. She said: “Her symptoms fluctuated between moderate to severe to moderate, so they weren’t at a level where I would have been comfortable discharging her from mental health services completely.”
She realised that Ellie would need to be referred to adult mental health services, as she had not made “enough progress” to be discharged and was approaching her 18th birthday.
A transition meeting took place on November 8th 2018, which is when Ellie’s care was handed over to the adult mental health service and she began to have regular therapy appointments with Karl Abbott, an assistant practitioner in clinical psychology.
Ellie’s mother told the inquest that, despite having had a number of appointments with Mr Abbott, Ellie had not felt that these appointments were helping her. But Mr Abbott told the court that, the last time he had seen her, there had been a “positive progression” and Ellie seemed more engaged and less anxious.
However, she made another suicide attempt on July 31st 2019 which required treatment at A&E, two weeks after Ellie’s seeing Mr Abbott on July 16th.
Her care was eventually handed over to consultant psychiatrist Dr Patricia O’Malley, at the Priory Hospital in Altrincham (right). Dr O’Malley told the inquest that Ellie was referred to her on November 25th and attended an outpatient clinic with her on November 28th. Dr O’Malley said that she did a detailed assessment with Ellie, during which it became apparent that the teen was using alcohol which was having a negative affect on her mental health. “She said she was using alcohol because she was socially anxious, so she was aware that she was using alcohol to cover up distressing feelings. She said when she was drinking she frequently got into trouble with arguments or by trying to harm herself.”
The psychiatrist added: “I thought she had features of depression and anxiety but also features of an emerging unstable personality. She was only 19 at the time so her personality wasn’t fully formed, but there was an emerging unstable personality.”
After the assessment, it was recommended that Ellie be admitted to the Priory as an inpatient that night, and she was put on close observations.
Dr O’Malley told the court that Ellie’s mood was rapidly changeable and that her symptoms were indicative of an emerging emotionally unstable personality disorder, also known as ‘borderline personality disorder’. She began to see Ellie twice a week, once a week in a one-to-one appointment and once a week with other therapists and ward nurses and doctors.
She said: “I talked to Ellie about her mood and she was very clear that her mood was changeable and she found it very distressing, so we talked about introducing a mood stabiliser called Quetiapine, a 50mg dose.”
Although referred to as a “mood stabiliser”, Quetiapine is in fact an anti-psychotic drug.
Ellie’s dose of Quetiapine was later doubled to 100mg and, in December, she told Dr O’Malley that she felt well. She was keen to be discharged so that she could return home. It was decided that Ellie would go home for a period of temporary leave until December 23rd, to assess whether she was ready to be fully discharged or not.
Dr O’Malley said: “When Ellie returned on December 23rd she told me that the leave had gone really well and she’d had time with family and friends and was a bit anxious at times but was fine and hadn’t been drinking alcohol. But Ellie’s mum gave a very different picture: she said Ellie had been out both nights and they hadn’t seen much of her, that she had used alcohol and when she drunk alcohol it very clearly had an impact on her mood.”
But Ellie was still keen to be discharged, so it was decided that a second period of leave would be tried over Christmas, with Ellie due to return to the ward on December 27th.
“When she returned on the 27th things had deteriorated, she was in a very, very distressed state“, Dr O’Malley said, “she admitted she had been drinking and then said to me ‘I now realise that alcohol is a big problem for me’ and she wants to be back in hospital and to do the addiction programme.”
Dr O’Malley said that Ellie engaged with the programme and, though she found it especially difficult and very challenging, she was “doing well“.
At this point, the report states that “Ellie’s medication had also been increased, with her on a higher dose of both mood stabilisers and antidepressants.” This is the one and only mention of antidepressants in the article. Although it cannot be verified from this report, it is possible that Ellie may well have been on antidepressants for several years.
The last time that Dr O’Malley saw Ellie was on January 30th, a week after she had been discharged as an inpatient at the Priory, and she told the court that Ellie “looked tired“. She added: “She told me she’d not had any alcohol but had initially had a lot of craving, she did tell me there had been some ongoing issues with friends and that some people were making nasty comments about her on social media.”
Dr O’Malley said that what she called Ellie’s ‘mood stabilisers’ were once again increased, as her moods were still “up and down.” However, she told the court that she had felt it was the right time to discharge Ellie from inpatient care: “It was only a discharge from inpatient so she would have still been having aftercare and ongoing treatment, but felt it was right for her to move to outpatient care.” Sadly, less than three weeks later, Ellie lost her life.
Dr O’Malley said that it was “a shock” to hear about Ellie’s death, as she did not believe that the 19-year-old was a suicide risk, but Ellie’s family told the court that they felt they had not been given adequate warning that she was still in a “fragile” state. Her mother Elaine told the court that she felt she had been “lulled into a false sense of security” as she believed that Ellie was much better, but she was in fact still struggling.
She said: “My main concern was we would have liked to have been aware of how fragile she was when she left The Priory. We’d become a bit complacent really as we thought she’d turned a corner, but if I was aware of how fragile she was that month we wouldn’t have been so complacent.”
But Dr O’Malley defended the decision to discharge Ellie from inpatient care and told the court: “If Ellie had been thought to be a suicide risk she would not have been discharged.”
At the conclusion of Ellie’s inquest, the court heard that prior to her previous suicide attempts, she wrote notes which expressed her desire to die – at the time of her death, no such note was written. For this reason, coroner Tanyka Rawden (right) recorded a verdict of misadventure and told the court that she believed Ellie did not mean to die.
She said: “I’m going to find misadventure, which is an act with unintended consequences, so whilst I think she did take her own life I don’t think she meant to. It’s likely that this act that she did was an expression of her distress rather than an attempt to take her own life, I think it was something that was impulsive – we may never know what triggered it. I don’t think that was her ultimate aim. I think she was distressed and trying to express that distress through an impulsive act. Ellie was a very poorly young lady with a personality disorder which made her act impulsively.”
In the USA, the authorities recognise that young people are at greater risk of harm, and discourage the prescription of SSRIs to anybody under 25. The UK has similar guidelines for children under the age of 18.
However, all prescribers in the UK are duty bound to adhere to what is in the British National Formulary, from which they prescribe. This contains the paragraph: “The use of antidepressants has been linked with suicidal thoughts and behaviour. Where necessary patients should be monitored for suicidal behaviour, self-harm or hostility, particularly at the beginning of treatment or if the dose is changed.” Changing the dose includes increasing, decreasing or stopping the dose, as well as adding another psychotropic drug.
Neither the coroner nor the three medical specialists who testified at Ellie’s inquest mentioned to the court that prescribing antidepressants and anti-psychotics to a teenager, and then increasing the dosage on numerous occasions, might well have induced akathisia and, consequently, “made her act impulsively”.