On September 2, 2018, in the early hours of the morning, Samantha Jane Gould, a teenager living in the Cambridgeshire village of Fulbourn, took a “very large quantity” of prescribed medication she had picked up from her pharmacy the previous afternoon.

The main cause of Ms Gould’s death was her borderline personality disorder, which caused “persistent but unpredictable and fluctuating risk or serious deliberate self-harm and suicide”, coroner Nicholas Moss reported last month (May 28).

However, Mr Moss found in a “wider narrative conclusion” that a “systemic weakness and failing in the lack of a protocol” meant the Child and Adolescent Mental Health Service (CAMHS) and the GP service did not “communicate with local pharmacies concerning 16-18-year-old patients with mental health conditions who were at risk of deliberate overdose”.

CAMHS and Ms Gould’s GP surgery were contacted for comment, but had not responded by the time of going to press.

A spokesperson for Cambridgeshire and Peterborough NHS Foundation Trust said: “We offer our sincere condolences to the family and friends of Samantha Gould, and we will look to continue to work with all partner organisations in light of the findings made by the coroner.”

Pharmacy had no access to patient’s safety plan

An agreed safety plan with Ms Gould’s consultant psychiatrist put the responsibility for her medication with her parents. On August 30, 2018, Ms Gould’s psychiatrist changed her prescription to include topiramate, giving Ms Gould a paper prescription.

According to the coroner’s report, Ms Gould expressed a preference to tell her mother about the change in medication. The psychiatrist had to make a judgement call as to whether or not to breach medical confidence. She chose not to, and Ms Gould did not tell her mother about the new prescription.

The following day, Ms Gould attended her local pharmacy, with a prescription for topiramate and lorazepam. She collected those medications as well as some older prescriptions for other medications she did not know were being held there.

After taking a large amount of the prescription medications, Ms Gould went to bed and died “within at most a couple of hours”, the report said.

“The local pharmacy (who do not have access to patients’ records on SystmOne) had not been told about the safety plan. As Sam was 16-years-old, she was assumed competent to take her own prescriptions and the pharmacists had no immediate reason not to provide them to Sam, being ignorant of the safety plan,” the coroner claimed.

The pharmacy named in the report declined to comment when contacted by C+D.

“No national guidance” on sharing plans with pharmacy

Mr Moss found that there “did not appear to be any national guidance or standards” that encourage “appropriate sharing of risk information and care plans with the local pharmacy”.

“Had the pharmacy been aware of this plan, it is likely that they would either have refused to provide the medication with which Sam overdosed or, at least, contacted Sam’s parents or general practitioner,” he wrote.

While a local protocol has now been introduced to advise pharmacies of relevant care plans for 16-17-year-olds, the coroner expressed the need for “action […] at a national level” to “ensure that pharmacies are appropriately involved in medication safety plans for mental health patients aged 16-17”.

RPS: Pharmacies would welcome greater collaboration

As well as local stakeholders, the coroner’s report was sent to the Royal Pharmaceutical Society (RPS), the General Pharmaceutical Council (GPhC), the Company Chemists’ Association (CCA) and NHS England and NHS Improvement (NHSE&I).

Professor Claire Anderson, chair of RPS in England, described this “tragic case” as “desperately sad for the family and all involved”.

“Pharmacy teams provide vital support every day around mental health and would welcome greater collaboration around medicines safety plans for patients with mental health issues,” Professor Anderson commented.

“Information is central to better patient outcomes, more informed clinical decisions and a greater understanding of the patient’s condition. Pharmacists are the experts in medicines and having access to the patient’s full health record would enable provision of more holistic support, as well as improving high quality, safe and effective patient care,” she added.

A spokesperson for NHSE&I said that it does not comment on individual cases, but the commissioner pointed to its commitment to digitalising clinical processes across healthcare as part of the NHS long-term plan, “reducing time and costs but most importantly enhancing safety”.

The GPhC said it had “noted the coroner’s report” and “will respond in due course”.

Malcolm Harrison, chief executive of the CCA said the organisation “is aware of this extremely sad case and is currently considering the recommendations outlined in the notice. We will respond to the deputy coroner in due course”.