A production editor found hanged at home by her mother had been classified a ‘low suicide risk’ despite attempting to kill herself three times in four weeks, an inquest heard.
Katie Kemp, 23, was not treated as an urgent case by health workers in Merton, south west London, because she told them she was not planning to harm herself, despite being assessed as a ‘high-risk’ case days earlier.
Now a coroner has demanded health chiefs come up with an action plan after hearing Miss Kemp died just hours after meeting nurse Dhare Joseph, who sent her home despite her making three suicide attempts in four weeks.
The inquest also heard she had been referred to the mental health in mid May 2017 but an appointment was not scheduled until the end of the month ‘because they could not contact her’.
Katie Kemp, 23, pictured left and right, was found hanged at home by her mother after struggling with depression
GP Dr Alexandra Dudley-Cooke had previously assessed her and wrote the referral to the Merton Mental Health Team, run by South West London and St George’s Mental Health NHS Trust, due to the seriousness of Katie’s depression.
Questioning Mr Joseph, coroner Dr Shirley Radcliffe said: ‘A very young girl with three attempts at a suicide in four weeks who says she is suffering from feelings of hopelessness, who has consistent suicidal thoughts.
‘She has feelings of not just hopelessness but worthlessness and low self-esteem. ‘
What is it about those features that would suggest that you would consider risk to be low?
‘I am struggling to understand why these features present would make you think her risk was low.’
Mr Joseph replied: ‘I asked her what’s your plan today – do you have the intention of killing yourself – and she said “no”.’
Father Martyn Kemp, told the inquest: ‘We as a family agree, she shouldn’t have been allowed to leave the building without someone more senior seeing her.’
On the day of Miss Kemp’s death she was sent home by a mental health nurse after she was classed as ‘low risk’
Dr Radcliffe added: ‘Can you understand the parents’ concern that she had three suicide attempts, then has an appointment to see you as a result of that referral and essentially you’re saying to her – continue the same.
‘You can understand how she might have felt – that there hadn’t been any change or alternative offered as a way forward for her when she feels so utterly helpless.’
Mr Joseph had only been working with the mental health team for three weeks before being assigned to Katie, previously he had worked with alcohol and drug addicts.
Dr Dudley-Cooke, had been qualified since 2011 and had six months of psychiatric experience and was ‘well aware’ of how important it was for Katie to get specialist help, the inquest heard.
Miss Kemp went home with her mother after the appointment on May 30 said she was feeling tired and went up to her bedroom.
An hour later Mrs Kemp went to check on her and found her hanging in her wardrobe.
Dr Radcliffe said: ‘She needed to know that the symptoms she had were being taken seriously and sadly that was not the case.
‘We do not know if there had been the offer of some assistance that might have changed things.
‘We have heard from the trust, their investigation and how they are still thinking things through and how to do things better next time.’
Miss Kemp, who lived with her family in Merton, was described as ‘intelligent and attractive,’ she received a first class degree and had been working for a bio medical company.
She was a keen mountaineer and had been travelling with her boyfriend in Central America but had to return home after she attempted suicide, Westminster Coroner’s Court heard.
Miss Kemp was told by her GP that the Merton Mental Health Team would ring her but when she saw her GP again on 9 May, she said that she had a few missed calls from an unknown number but no messages.
An inquest heard Miss Kemp, pictured, had tried to kill herself three times in four weeks and health bosses in Merton are due to appear in court in April to explain how they intend to improve services
Her GP’s referral was received by the mental health team on 11 May and it was allocated to Mr Joseph on 18 May.
There are three categories for referrals – emergency, dealt with in 24 hours; urgent, within a week and routine, within 28 days.
Dr Radcliffe said she was concerned why GP’s referral was side-lined as ‘routine’ when it was clearly ‘urgent’ and why Mr Joseph was not provided more support from senior clinicians.
Merton Health Officials are due to appear before the court in April to explain how procedures are to be improved.
The coroner concluded that Miss Kemp had committed suicide as a result of her depression.
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