On April 8th 2017, 16-year-old schoolgirl Karen Edgar (top) was found by her mother in her bedroom at home in the village of Little Clifton in Cumbria. She was taken to West Cumberland Hospital in Whitehaven, but was pronounced dead in the early hours of the morning. She had hanged herself.
Shortly after her death, Karen’s parents Derek and Julie Edgar said: “We are devastated by Karen’s death. She was an intelligent and sociable girl, who was loved by so many people. Karen was excellent academically and wanted to pursue a career in medicine following her A-Level exams. She was also really looking forward to her school prom.”
Mark Bedford (left), deputy head teacher at Workington Academy, also paid tribute, saying: “Karen was a dedicated student who always strove to do her best academically. She showed a passion for creative subjects, expressing herself vividly in her writing. Karen was well respected by both staff and students. She will be remembered as a polite student and as a loyal friend with a great sense of humour. Hers was a life with great potential and we feel her loss deeply.”
Friday’s News & Star reported on the first day of the inquest which had begun the previous day. The court heard that Karen had been referred to the Child and Adolescent Mental Health Services (CAMHS) in October 2015 and had received “care and treatment” throughout the period leading to her death.
Elaine Graham, senior practitioner, said that Karen had presented with issues including suicidal thoughts, low mood and lack of appetite and had been treated for depression. She was taking antidepressants.
Six months before she died, Karen had been admitted to hospital after overdosing on paracetamol. But Mrs Graham said it had not been an attempt to take her life and Karen had never acted on her suicidal thoughts.
Today, the News & Star reported on the final day of the inquest. Karen’s mother, Julie Edgar, described her as a beautiful and intelligent girl, telling the court: “She was thoughtful and she had a massive heart.”
Karen’s grandmother Mary Edgley added: “Karen had a degree of empathy that was outstanding. I’ve never met anyone like her, she had more insight than mature people.
The inquest heard that Karen had been prescribed antidepressants after only two one-to-one sessions, whereas, the court was told, guidance issued by The National Institute for Health and Care Excellence (NICE) states prescriptions should be made after four to six sessions.
However, in CG28, NICE states that an antidepressant (Fluoxetine) should be prescribed only for patients suffering from moderate to severe depression. If Karen was able to attend school regularly, then she was, in all probability, not in this category.
Because of the heightened risk of suicidal ideation, even more prevalent in children, the advice for treating patients with mild depression is: “Do not use antidepressants routinely to treat persistent sub-threshold depressive symptoms or mild depression because the risk-benefit ratio is poor.”
This is part of the original guidance for treating children with moderate to severe depression:
- 188.8.131.52 Offer children and young people with moderate to severe depression a specific psychological therapy (individual CBT, interpersonal therapy, family therapy, or psychodynamic psychotherapy) that runs for at least 3 months.
- 184.108.40.206 If moderate to severe depression in a child or young person is unresponsive to psychological therapy after four to six treatment sessions, a multidisciplinary review should be carried out.
- 220.127.116.11 Following multidisciplinary review, if the child or young person’s depression is not responding to psychological therapy as a result of other co-existing factors such as the presence of co-morbid conditions, persisting psycho-social risk factors such as family discord, or the presence of parental mental ill‑health, alternative or perhaps additional psychological therapy for the parent or other family members, or alternative psychological therapy for the patient, should be considered.
The excuse offered by Dr Barry Chipchase, (right), clinical director for CAMHS, for contravening NICE Guidelines was: “The people that assessed Karen thought she wouldn’t use psychological therapy in a way that would be effective.”
Nevertheless, Dr Chipchase admitted failings within Karen’s care, including the lack of a clear care plan, the lack of availability of family therapy, a failure to monitor the teenager closely when medication was introduced or changed, and the absence of a multidisciplinary team meeting around Karen’s case.
Coroner David Roberts (left) recorded a conclusion of misadventure. Referring to Karen’s empathy and insight, he said: “I’m satisfied this was not a deliberate act to end her life. She hanged herself but had intended to be found by her mother.”
Mr Roberts added that he would be writing to the NHS Cumbria Partnership Foundation Trust and to the Secretary of State about failings in the care Karen was given prior to her death.
Speaking after the inquest, Karen’s parents Derek and Julie Edgar said: “We are still devastated following the events of last year and the tragic loss of our beautiful daughter Karen…
“We as a family asked for professional help from CAHMS and the services that were provided fell far short of what could and should have been expected.
“We have worked closely with the NHS over the last year to provide feedback to improve practice within the CAMHS service and we sincerely hope the findings and recommendations for improved child services are taken on board and implemented.
“We never believed Karen had meant to take her own life and this has now been validated by the coroner’s misadventure verdict.”
Following the inquest, Clare Parker (right), director of quality and nursing at Cumbria Partnership NHS Foundation Trust said that Karen and her family were not delivered the high standard of service the trust strives to achieve and an investigation had been carried out.
She added: “As a result of this investigation we have made a number of improvements, particularly to processes, within our Child and Adolescent Mental Health Service teams. Along with other improvements we are undertaking a unique piece of work to have risk assessments, care plans, mental health assessments and correspondence with GPs all in one place electronically. This will make the processes much more robust and enables services to flag issues earlier.
“We have listened to what the coroner has had to say and will be looking at this case again to ensure that all possible lessons are learned from this tragic event.”
The main lesson that should be learned by both Mr Chipchase and Ms Parker is that the reckless, off-label prescribing of antidepressants to children can, and frequently does, have fatal consequences.