The New Mother and the Psychiatrist

On June 14th 2017, 39-year-old Rebecca Kruza (top) took her 7-month-old son Henry with her to visit her mother at her home in Alkham, near Dover. She arrived around noon, ahead of an appointment to discuss her medication later that day.

After a while, Rebecca told her mother, Lyn Richardson, that she was going for a rest. Lyn left her for some time before picking up Henry and going upstairs to wake her so that she would be ready in time for her appointment. Tragically, she found that Rebecca had taken her life by hanging.

On Monday this week an inquest, scheduled for three days, began at the Guildhall (right) in Sandwich. The inquest heard that Rebecca, a former insurance underwriter, lived in Hawkinge with Simon McPhee, her partner of 20 years. Henry was born in October 2016 and, despite the fact that Rebecca had had a particularly difficult time giving birth to her son, spending two days in labour, she seemed in good spirits in the days that followed.

Henry was born with tongue-tie, preventing him from feeding properly, and suffered from colic, crying throughout the day and night. As a result, Rebecca suffered from sleep deprivation and Lyn said it had an effect on her daughter’s well-being: “She was desperately trying to help him because he was obviously so distressed”.

Rebecca went to her GP several times but, after many weeks of waiting for referrals, she and her partner paid a private paediatrician to treat the tongue-tie in January 2017. Afterwards, Henry began feeding properly but, despite this, her own sleep did not improve.

Rebecca told her GP that her sleep deprivation was becoming insomnia and that she was suffering from anxiety. In April 2017, she was referred to the mother/infant mental health service. She started seeing a mental health consultant and at around the same time was also visiting a holistic remedy specialist. However, Lyn said that she did not believe any of the methods used were helping her daughter, whose insomnia continued to get worse.

Rebecca and Simon decided that she would begin seeing a private psychiatrist from the Priory Group who prescribed her the antidepressant Mirtazapine.

Lyn told the inquest that her daughter had a historic intolerance to medications and, although Rebecca complained that Mirtazapine was making her anxiety worse, the dosage was originally increased before she was taken off it. She added that this was not the only medication she had been prescribed and that at one point she had “begged” to be allowed to stop taking Mirtazapine.

Lyn, who went with her daughter to one of her appointments, stated that she felt the psychiatrist to be “dismissive” of her daughter’s problems.

She described her daughter as being “very distracted” and “edgy” during the day she died, that she refused to eat, had been unable to listen to music and had repeatedly told her she could hear a noise in her head. Lyn said that while her daughter had previously expressed concerns about her mental health, she had never given any indication that she intended to kill herself: “People quite commonly think they want themselves dead at some point, I would say 99 per cent of the population do. But she never said: ‘I’m suicidal. This is what I am going to do’.”

In KentLive’s report of the second day’s proceedings, the “dismissive” psychiatrist was identified as Dr Agnieszka Klimowicz (left) from the Priory Wellbeing Centre in Canterbury. The court heard that in addition to other medications that she was already being prescribed, Dr Klimowicz gave her a prescription for the antidepressant Mirtazapine with the aim of helping her get to sleep.

Rebecca, who had a history of intolerance to medication, complained that the Mirtazapine had made her anxiety worse. In an email sent to Dr Klimowicz two days before her death, Rebecca told her she was “really struggling” with the drug, that she was “shaking, feeling spaced out and awful”.

During the inquest, Dr Klimowicz stated that she had advised Rebecca days before her death to cut down her dosage of the drug and, if she felt the side effects to be overwhelming, she should stop taking it altogether. The report did not mention testimony heard the previous day that the dosage had been increased before this advice was given.

The family’s advocate, Craig Carr (right), said that it was not recorded in Dr Klimowicz’s notes that Rebecca had been told to stop taking Mirtazapine if the side effects were becoming too much.

Dr Klimowicz said that she did not believe that Rebecca was an immediate danger to herself and so did not feel it was necessary to set her up with a daily meeting with the crisis team. But she advised her to call the team if she felt unsafe or that she was going to cause harm to herself.

Mr Carr highlighted what he saw as a lack of communication between Dr Klimowicz and Rebecca’s NHS therapist and said that correspondence between the therapist and her GP was “slow”. He said: “There were a number of people involved in Rebecca’s care. There was no lead and there was a lack of communication between them. This apparent view is that where there’s a private psychiatrist, there’s simply no need to communicate with them. As you heard from Dr Klimowicz, there appears to be an absence of procedure on either side.”

He also stated that there was a lack of services available to mothers with mental health problems in Kent at the time of Rebecca’s death. He said: “There were apparently no mother and baby units at all so that if a mother did want to be seen, that was not an option in Kent. She would have had to have been referred further afield. We have heard the situation may have changed since then, whether there’s adequate provision is something that needs to be considered.”

Mr Carr addressed coroner Alan Blunsdon (left) about his having, potentially, to submit a report about the prescription of Mirtazapine in order to prevent further deaths, stating that there is emerging evidence of increased self-harm” in relation to the drug.

The coroner said the issue presented him with “many difficulties” but that he would “not dismiss it.”

On the final day of the inquest, the coroner delivered his conclusion that, based on the extensive evidence he’d heard, Rebecca had intended to take her life. He called Dr Klimowicz’s evidence “unreliable“, but said: “There was nothing that anybody could have reasonably done to prevent this tragic event. Hindsight has to be ignored.” He added: “I’m satisfied that when Rebecca arrived at her mother’s house on June 14, she had then or sometime around then worked out a plan that she would take her own life.”

Rebecca’s family were particularly concerned about the prescription of Mirtazapine, as one of its side-effects is that it can increase suicidal ideation. However, Mr Blundson stated the drugs she took had a “minimal effect” on her condition.

This conclusion shows a wilful disregard by the coroner of what he had heard during the previous two days.

  • The family’s advocate provided evidence that there is “emerging evidence of increased self-harm” in relation to Mirtazapine.
  • Testimony from those who knew Rebecca showed that she became more agitated after Mirtazapine was added by Dr Klimowicz to the unnamed medications that she had already been prescribed by other professionals.
  • Rebecca knew the effect that Mirtazapine was having on her state of mind, which is why she begged to be taken off the medication.
  • Dr Klimowicz should surely been aware that the risk of suicidal ideation is increased when an antidepressant is taken alongside other psychotropic drugs.
  • Moreover, a warning about antidepressants in the British National Formulary, the official prescribers’ handbook, states: “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”. Dr Klimowicz prescribed the drug, then increased the dosage, then told Rebecca she could either reduce the dosage or withdraw the drug altogether.
  • Arranging weekly appointments and passing on the phone number of the crisis team turned out to be an inadequate form of monitoring, especially at a time when the dosage was being changed.

Jim Gladman (left), a solicitor representing the family, released a statement on behalf of Rebecca’s mother Lyn and sister Kathryn. He said: “Our world fell apart on the day we lost Becky. She was a beautiful soul who loved life and had every reason to live. Her death was unexpected, shocking and tragically unnecessary. We know she was struggling with her mental health after having her baby but she was seeking help from various professionals. We feel that those professionals sadly let her down in her care by failing to liaise between themselves to safeguard Becky and her baby and to send vital referral documents in a timely manner or with urgency

We hoped that the findings of this inquest would help bring about change to see sufficient support given to women experiencing postnatal depression, so that this does not happen again to another mother and family. We welcome the coroner’s decision to make enquiries about the referral process to the mother and baby unit, the number of mother and baby unit places available in the area, and plans for increasing them.

In our grief we, as a family, have anguished endlessly over what we might have done to save Becky. We ask that those practitioners involved in her care now reflect on the events leading up to her death and consider how they would act in a similar situation in future.”

Related Articles:

Medicating Post-Natal Depression

Post-Natal Depression and Antidepressants

In memory of Donna and Zaki

Rachel: Matters of Concern

Citalopram and the Unborn Baby

Treated at the Priory

A Sunday Afternoon in Summer

 

 

3 Replies to “The New Mother and the Psychiatrist”

  1. I was very struck by this study from the University of Nottingham where Mirtazapine was found to have 3.7 times the suicide deaths as Fluoxetine. It has to be said that there is potential confounding for severity of depression, and I believe Mirazapine is usually tried as a second line after an SSRI.
    https://www.bmj.com/content/350/bmj.h517

  2. When Mirtazapine was used to counter the effects of Sertraline and Amitriptyline used in combination, sending my son psychotic, hallucinating, then hypomanic – possibly serotonin syndrome – the Mirtazipine did work in his favour to some extent, so he used it only briefly.
    However, he was not helped to taper it off sufficiently, and two years on from his last pill, the withdrawal effects are appallingly debilitating and he is unable to work. Love of his sons prevents him from suicide. Naturally, no GPs warned him of the outcome.

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