Why didn't doctors say my daughter was suicidal?

The mother of a teenager who told a doctor that she planned to kill herself before taking her own life has questioned why doctors did not tell her.

Issy Phipps, 17, was student at Hartpury College in Gloucester. She died at her home in Cookham, Berkshire, in April 2023.

Despite telling a GP her plans the day before, and speaking to a mental health nurse, no medical professional contacted her next of kin and a referral was never followed through.

"I can't understand why they wouldn't ring next of kin to make her safe," said her mother Sarah Renton.

Issy was a talented singer and had played rugby all her life for Berkshire, Maidenhead and Reading. She had also recently won gold as part of the England Under 18s touch rugby squad.

But she also suffered from depression and had been prescribed an antidepressant drug when she was 16.

She was selected for a place at a rugby academy run through Hartpury College where she boarded, and was doing well.

But she was still suffering with her mental health, so a doctor in Gloucester put her on a new antidepressant drug, which has been claimed to cause suicidal thoughts.

Her parents were not informed.

On 28 April 2023, Issy attended an emergency GP appointment at Staunton and Corse GP Surgery in Gloucestershire.

She told a trainee doctor she planned to take her own life at home that weekend and said her parents would be away.

The GP referred her to Gloucestershire Health and Care NHS Foundation Trust's first point of contact centre. A mental health nurse called and spoke to Issy who she repeated her plan.

The nurse contacted the county’s crisis resolution and home treatment team, which said it would not be able to help, as Issy would be back home and out of their area.

Berkshire Healthcare NHS Trust also rejected her referral, telling the nurse that it needed to come from a GP.

No-one called Issy’s parents.

"There was a duty of care. I don't know how anyone could watch a minor walk out the door without knowing 100% she was safe," Ms Renton said.

"She was massively let down."

Issy took her own life the following day.

In the moments before, she posted old photos on her family's WhatsApp group with the message "will always family" and a pink heart emoji.

"She loved family," her mother said.

"She was very likeable, she could talk to anybody. She was warm, funny and very popular.

"I definitely feel like Issy should be here. She was having a crisis.

"A lot of simple things could have been done better - just ring the family, make them safe. We all need that at our lowest. Someone we love to just be there and say it's going to be OK.

"Issy didn't get that."

Both Gloucestershire and Berkshire health trusts have carried out internal reviews.

Gloucesterhsire Health and Care NHS Foundation Trust said in a statement: “We have worked with partners in Berkshire to identify what more could and should have been done to keep Issy safe and try to prevent this tragic outcome.

"We will ensure that learning from both the inquest and our own internal review is embedded into practice, in the hope that we can prevent similar outcomes in the future."

Berkshire Health Trust said: “We have put in place processes to improve communication in cross-border referrals including ensuring that a conversation between clinicians always takes place where crisis support is requested by someone outside of the county."

Ms Renton hopes talking about Issy will help others in the future.

"Issy went to a professional to ask for help," she said.

"She knew she wasn't well yet she still found herself on her own."

"Issy's is not an isolated story. There are too many. We need to do better. The guidelines are there and make sense, so maybe we just need to enforce them and make sure everybody is getting the same level of care and not falling through the cracks."

"I honestly believe that in a different area, with a different GP, it could have been a very different story."

Alison McCormick, assistant coroner for Berkshire, concluded that: “On the balance of probabilities the lack of notification of Isobelle's disclosed plan to end her life to her parents made a more than minimal contribution to her death.”

If you have been affected by any of the issues raised in this story you can visit BBC Action Line.

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