On 6 February 2017 commenced an investigation into the death of Kate Dolby, aged
36. The investigation concluded at the end of the inquest on 28 March 2017. The conclusion of the inquest was suicide. Kate took an overdose of Propranolol after carrying out research into this_ Please note that the issuing of this report has been deliberately delayed, for the reasons set out below.

The family advised us that Ms Dolby preferred to be referred to as Kate, so will respect that wish in this report: Kate was born on 29.8.80. Her past psychiatric history included an eating disorder when she was a teenager. She had also been prescribed anti-depressants when she was a student: She appears to have suffered an acute psychotic episode in April 2016, resulting in her detention (under s2 of the Mental Health Act) on 10 April 2016. She remained an inpatient at Millbrook until 13 May 2016. During this admission, on 19.4.16, a call was made to the Early Intervention in Psychosis (EIP) team, as it had been decided that Kate should be referred to them. There was confusion about this call. We heard that there are 2 EIP teams 1 for city and 1 for county: The call was made to the county team_ Kate's GP surgery is based in the city. The call, it was also suggested, did not provide enough information for the referral to proceed. Common sense suggests that more information should have been requested, and the referral passed to the correct team. Instead, only a week later, the referral was simply closed. Kate was not even on the waiting list between 26 April and 3 June 2016 This is a clear breakdown in communication which caused delay to a patient awaiting treatment: The only post-discharge review that Kate had after leaving Millbrook on 13 May was a standard 7 review by the Crisis Resolution Home Treatment (CRHT) team, who felt her well enough to be discharged from their team, to await review by the EIP team. This we know did not in fact happen for a further 4 months_ day

It was only after Kate's discharge from Millbrook that she was re-referred to the EIP team, on 3 June. She effectively went to the back of the queue again, and we have heard that there was a significant waiting list at that time_ During this time; her GPs were becoming increasingly concerned for Kate_ A letter from the GP to her psychiatrist dated 14 June (and chasing letter 9 August) was only replied to by on 23 August and received by the GP practice on 31 August 2016. In her letter, says she was worried that Kate may be in the early stages of psychotic relapse, and copied the letter to the EIP team. The EIP team say they never received letters from the GP or from This is a further, worrying breakdown in communication, Kate was clearly struggling in the months before she was seen by the EIP team. Her GPs were adjusting her medication as best they could, whilst awaiting input from mental health services. During this time, she was prescribed a month's worth of 40 mg Propranolol (84 tablets) , for treatment of anxiety symptoms Kate's family and housemate became increasingly concerned about her. She attended the Emergency Department on 27 July saying she felt suicidal She was triaged by an EIP nurse on 13 we heard that this was part f the process started by the trust to deal with long waiting lists The nurse who saw her stated she thought Kate was at risk of relapse without further support. It was only after a phone call from Kate's GP directly to the EIP team on 19 September 2016 however; a full 2 months after that; and 5 months after she was first referred to this service, that things started to happen: Kate met her care coordinator, on 22 September asked ((consultant psychiatrist with the EIP team) to see her urgently. She said she was aware how long Kate had been waiting; and that she was concerned about her low mood. ffitted Kate in before her usual clinic appointments, on 27 September 2016. Although Kate talked to both clinicians about thoughts of suicide, she said she had no plans to carry this out: She was seen and contacted regularly by lafter 27 September, and seemed to be doing well: Her housemate described "seeing some of the old Kate coming back"_ Her father told us that she seemed the happiest they had seen her for a long time, just a couple of days before her death_ Sadly, we know that Kate was found dead at her home address on 9 October 2016. Her cause of death was Propranolol toxicity. The police witness told the court Kate had previously carried out research on her phone about how to overdose using Propranolol She had no previous history of accidental mixing up of tablets or dosages_ question was whether earlier referral to the EIP team would have made a difference for Kate candidly accepted that it may have done. It is of course difficult to know with any degree of certainty: cannot say, to the required standard of the balance of probabilities, that earlier treatment would have avoided her death. The trust has not sought to or dress up the undoubted failings in this case, which has been helpful to this investigation. There was and breakdown in communication at multiple stages, resulting in significant delay in Kate receiving the help she needed. It was more than 5 months between the first referral, which find was on 19 April, and her first meeting a care coordinator and subsequently a psychiatrist in this team. Kate's family quite rightly refer to a delay in support for her. That is the key issue in this case, and have heard evidence from ihe trust about changes that have been made to reduce July - key deny delay the risk of this happening again: We have heard that; because of national guidance issued in April last year, patients referred to the EIP service are now referred to a Single Point of Access, and allocated a care coordinator within 2 weeks. Early figures suggest the trust is very well with achieving this in the vast majority of cases_