TW suicide (including method of death),
Sasha’s family said: “Sasha had so much to live for and she tried so desperately hard to get well. We feel that this inquest has shown the flaws and inconsistencies in the system that let her down.
On the day of Sasha’s death there was no clear crisis plan in place for staff to follow, and the psychiatric team at Frimley Park Hospital refused to see Sasha. Surrey and Borders staff did not revoke Sasha’s Section 17 community leave, leaving her at high risk to herself in the community. Sasha was often dismissed by some staff as they labelled her as attention seeking, due to both incorrect suspicions of Emotionally Unstable Personality Disorder and rumours – which were completely unsubstantiated - of her having Munchausen’s (Factitious Disorder).
We hope that by shining a light on these issues, actions will be taken to prevent other young adults and their families having the same experience. We welcome the coroner’s decision to write three reports to prevent future deaths.”
Sasha’s family said: “Sasha was our gorgeous girl, a precious daughter, a loving sister, a loyal friend, and a spark of brightness in the lives of all those she knew.
Sasha’s health worsened when she was transferred from Child and Adolescent Mental Health Services to Adult services. At this point we feel there was an abrupt decline in the care Sasha received and the therapy she had been receiving as a teenager simply halted. Sadly, this resulted in a swift decline in her physical and mental wellbeing.
Over two years since her death, and after a four-week inquest with seven other interested persons consisting of three hospital trusts, two police forces and two private GPs, a thorough investigation into Sasha’s death has finally taken place.
Sasha found the early hours the most difficult to deal with, when most mental health services are closed. As a result, we are fundraising to open a crisis house in Sasha’s memory, which will be open all night and will welcome all those who struggle as Sasha did.”
"On the day of her death Sasha attended Frimley Park Hospital (FPH). She asked to see a nurse from SaBP’s psychiatric liaison team, based at FPH, because she was experiencing suicidal thoughts. Staff at psychiatric liaison refused to see Sasha stating that she should return to the ward or approach the Home Treatment Team."
"Evidence was heard that some nursing staff based at Frimley Park Hospital believed that Sasha might have Factitious Disorder, a psychological disorder involving the feigning of symptoms. The evidence of clinicians was that even if some staff suspected that Sasha may have this disorder it did not affect Sasha’s treatment. However, Sasha’s family believe that this suspicion among staff, together with what the family consider to be a misdiagnosis of Emotionally Unstable Personality Disorder, and the fact that Sasha’s autism diagnosis was not confirmed until after her death, affected her treatment by both medical staff and the emergency services." [emphasis mine]
Sasha Inquest @SashaInquest reporting on the Inquest, 7 May 2019:
SM: You say Sasha presented with suicidal thoughts on background of EUPD, that's the only diagnosis you mention isn't it
CGC: yes
SM: That was the only diagnosis she presented with and you link it dont you
Coroner: There's two questions there, what diagnosis?
CGC: She presented to me with suicidal thoughts and OCD
SM: When you write suicidal thoughts on background of EUPD. Does that not link the clear plan between suicidal thoughts and EUPD?
CGC: Yes
SM: She's talking about overdoses to create butterflies in her brain, do you understand that to be a rational belief?
CGC: <pause> do I understand now?
SM: At the time? Did you think that was a rational belief?
CGC: I thought it was the way she presented her difficulties
SM: She said she had Drug 1, yes?
CGC: Yes
SM: So a young woman who presents as suicidal, isn't able to get an appointment with her care coordinator so she comes to you, you clearly link suicidal thoughts with mental disorder and she has the means to take her own life; isn't that sufficient to require a MHA assessment?
CGC: I didn't think that at the time, no
SM asks about positive risks
CGC: Allowing Sasha to take responsibility for her own life; positive risks was wanting to receive diagnosis of ASD so she was going to engage with services, that was a protective measure.
CGC: When she did take the overdose she called for help, so it was misadventure not a suicide attempt
SM: You say Sasha has a morbid obsession with death and dying. Did you think she was making it up at the time?
CGC: No
SM takes to email: You've explained it's as a result of further discussion with A&E staff. You don't sound like you're asking Dr Shuttleworth for an opinion, it reads like you're stating what you and other staff think. You state...
SM reads: 'I had long discussions with A&E staff who feel as I do that she presents with munchausens and fabricates disorders'. That appears to be a statement not a question, is that right?
CGC: Yes
SM: We've heard you didn't receive a response to that so did that stay in your mind?
CGC: Absolutely not, I'm a nurse, I'm guided by a consultant
-Thread of interview here: https://twitter.com/SashaInquest/status/1125787463337881600
Sasha Inquest @SashaInquest reporting on the Inquest, 20 May 2019:
SF [Steven Mark Forster, Sasha's father]: I had a text message from Angela at 11:30 saying she was at A&E trying to see someone at psychiatric liaison but they wouldn't see her. She asked me to call them, that had never happened before.
SF: We knew her behaviour was risky, as soon as I got that, I think I read it at 11:45, 11:46, I replied and said I'd do it and called psych liaison I'd never done it before and the number I had was wrong, had to find different number.
SF: I got through, at first they didn't want to speak to me but I insisted and was put through to Colette Griffin-Chapman. I explained Sasha was down in A&E, was with my wife and desperate to see someone in pscyh liaison.
SF: It was part of the plan, Sasha had suicidal thoughts and Ms Griffin-Chapman basically said it was not the plan, I should tell my wife they should go to Farnham Ward, they were too busy and wouldn't see her.
SF: She then began to explain to me that she was attention seeking, needed boundaries and she should take responsibility and go to Mulberry Ward. I got quite angry but still tried to maintain calm.
SF: I explained as far as we knew psych liaison was a port of call in crisis and she should check with staff on Mulberry Ward to check that, once she'd done so could she immediately see Sasha because it was important and I was conscious it was coming up to 12.
-Thread of interview here: https://twitter.com/SashaInquest/status/1130444684441133056
Note from PDV!: Following the inquest into Sasha's death has been heartbreaking and enraging. The clinicians insist that the opinions of those who thought she had EUPD or the compromise that she had "EUPD traits" did not effect her care, but it is made clear by the focus of her care on boundaries and containment that this is just not the case. Especially clear is the revolting attitude of the psychiatric nurse liason. Her opinion on Sasha not presenting in a way that she approved of and believing her to be "attention seeking" leading to her refusing to talk with Sasha was negligent and judgemental and vile--and who knows if Sasha might have made it through that day had she been able to follow what she believed to be her crisis plan. It is worth considering too that Sasha was autistic but attempts to investigate this were slow and clinicians dismissive of whether or not it even mattered, even though autism can look very very much like what clinicians label EUPD/BPD.
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