Written evidence from Dr Sangeeta Mahajan, Consultant Anaesthetist / Trustee at Guy's and St Thomas' NHS Foundation Trust / PAPYRUS (Charity for Prevention of young suicide)


Thank you for inviting comments.

I am a bereaved parent and a hospital doctor. I write to you mainly about Point 3 – “Ways to strengthen the Coroners’ role in the prevention of avoidable future deaths.”


Our son Saagar Naresh died by suicide on the 16th day of October 2014 at the age of 20. He had been diagnosed with Bipolar Disorder only 10 weeks before his death. There were multiple failings in his care by the Mental Health Team and subsequently, by our GP. We, as his family failed to do what was best for him as we were essentially kept in the dark about the seriousness of his condition as he was deemed to be an ‘adult’.


The inquest was to take place in June 2015 but was postponed very close to the date, to October due to lack of documentation from the GP. It finally took place over 2 days – first one in October and the second one in Dec 2015. The venue was Southwark Coroner’s Court. Finally it took 15 months for the inquest to be completed which, I think is too long.


The inquest was conducted with respect and we felt heard. We and our lawyer were given time to ask questions and share our concerns. I was granted permission to bring my son’s picture into the court room as I wanted to make a point that he was a beautiful young man who was much loved and treasured. Not just a number, which is how he had been treated.


The questions asked by the Coroner were thoughtful, considered and relevant. She was patient with the proceedings and these were her final conclusions:


1. There was a general failure to identify the diagnosis on the discharge summary from the Home Treatment Team to the GP.

2. There was a general failure to communicate thoroughly enough with the parents about the relapse symptoms, what to watch out for and where to go for help in the future.

3. There was a failure to assess SN’s risk of suicide in more detail by the GP and give more consideration to referral to secondary care and discuss the same with his parents given that his PHQ 9 score was 27/27.


At the end of the proceedings a Nurse Manager from the Mental Hospital in question (South London and Maudsley, SLaM) promised the Coroner in fancy jargon that the recommendations would be applied. However, nearly 6 years later, after numerous attempts at co-operative liaison, I have no reason to believe that effective changes have taken place. That Nurse Manager, I am told, has since left his employment with SLaM. I am not sure who is now responsible for taking his promises to conclusion. No meaningful audits have looked at the quality of discharge letters, handovers and engagement with carers. The impression I have is that the undertakings made in the court by the representatives of SLaM were designed to placate the Coroner rather than seriously address matters to improve services and prevent unnecessary loss of lives.


I am not aware of any actions taken by NHS England about the GP.


The time, effort and energy spent in carrying out an inquest properly is a waste if organisations refuse to learn lessons from preventable deaths. Given the defensive nature of internal/external investigations, many bereaved families have all too often seen them to be futile and pointless. Our hopes hinge on the Coroner’s Court’s ability and influence.


Given the rigidity and apathy of large institutions, unless there is a regulatory body like CQC (Care Quality Commission) actively involved in holding them accountable and monitoring the necessary changes being made in a timely fashion, it is unlikely to happen. That is a sad fact. I have reason to believe this as I now belong to a community to bereaved parents and have heard numerous accounts that reinforce this impression.


I recommend that the Coroner’s Court form strong links with regulatory bodies such as the GMC, CQC, NHS England and the like. Recommendations made at the end of every inquest be handed over to them so that they can place a special emphasis on the short-comings identified.


There are too many holes in the system and too many patients keep falling through the net. After hearing the horrific story of Saagar’s tragic death a colleague, Consultant Psychiatrist commented unsurprised, “This has been going on for as long as I can remember - 30 years at least.”


Please help.

Thank you.


September 2020