Young girl takes her own life despite warning her GP of her intentions

Isobelle ‘Issy’ Phipps was born on 12 September 2005. She lived with her family in Cookham, Berkshire and attended Hartpury College in Gloucestershire as a residential student, where she studied PE, Psychology, and English. Issy was a keen Rugby player and performed in the England Girls U18 touch rugby team, going on to secure Gold in the Junior Touch Championship in 2022.

On 29 April 2023, Issy sadly took her own life at her home. Despite clearly expressing to medical professionals of her plan and intent to do so, insufficient steps were taken to notify her parents which ultimately contributed to her death.

An inquest into Issy’s death was held on 16 and 17 October 2024. Issy’s family were assisted by Ben Davey and Tom Gardiner of Dean Wilson Solicitors, who instructed Shahram Sharghy, Barrister, of 1 Crown Office Row to represent Issy’s family at the inquest.

Background

On 28 April 2023, Issy attended an emergency GP appointment at Staunton and Corse GP Surgery in Gloucestershire, where her college was based. Issy’s family were away at the time away in Wales, and unaware of her plans, had approved her to leave the college to return home for a weekend with her friends.

During the appointment, Issy disclosed to the trainee general practioner, Dr Hassan, her feelings of low mood and intent to take her own life. She expressed clear plans to take her life that weekend by hanging herself in the garage of her home.

Issy was offered a referral to psychiatry under the Children and Adult Mental Health Service (“CAMHS”), however, being aware of the long waiting times to receive treatment, she declined.

Dr Hassan sought advice of his supervisor Dr Mungo Chambers, who told him to refer Issy to the Crisis Team. Dr Hassan provided Issy with the crisis team’s telephone number, however, being concerned that she would not make the self-referral he persuaded her to allow him to call the crisis team on her behalf.

Despite being aware that Issy’s family were away and that Issy intended to take her own life, neither medical practioner took the steps to notify and involve Issy’s family to ensure her safety.

Those present at the inquest heard during questioning as to why Dr Hassan did not take additional steps to attempt to contact Issy’s family, that “something in her body language made me feel that she wasn’t going to act on it.”

Issy’s crisis referral was received by Nicola Young, Community Mental Health Nurse, with the First Point of Contact Centre for Gloucestershire NHS Trust. The referral included details of Issy’s intent and clear plans to take her own life.

Ms Young telephoned Issy, who informed her that she would be returning from her college to her home in Berkshire that weekend. Ms Young discussed with Issy her plans to take her own life at her home this weekend.

Following her call with Issy Ms Young phoned the Gloucestershire Crisis Resolution and Home Treatment Team (“CRHTT”). She was advised to contact the Berkshire team, as she would be in their area for the weekend, and that the Gloucester team would be unable to help as Issy would be out of their area.

Ms Young attempted to contact Berkshire Healthcare NHS Trust; however, her referral was rejected, citing that it needed to come from a GP.

It was heard at the inquest from the speaker from the trust Louise Noble, that this was a misunderstanding by Berkshire’s internal staff and that this referral should have been accepted.

Despite emphasising Issy’s clear intent to take her own life the following day, Ms Young was unable to secure a referral from Berkshire and was not afforded the opportunity to speak to a clinician from the Berkshire area. Additionally, in the absence of securing a referral no further attempt was made by either trust to notify Issy’s parents of her intentions to take her own life.

Later that evening, Issy sent messages to her family and friends. Her parents attempted to contact her, but did not receive a response to their calls or texts. Issy’s parents asked a family friend to visit the house, who sadly found Issy deceased in the garage at the family’s home.

Emergency services attended the scene and despite attempts to perform CPR, Issy was pronounced dead at 11:51 pm.

Inquest

Having heard evidence from the parties over the two-day inquest, the Coroner, Alison McCormick stated in her conclusion: “the lack of notification of [Issy’s] disclosed plan to end her life to her parents made a more than minimal contribution to her death"

During the inquest Shahram Sharghy, representing Issy’s family, stated: “It does – and this is genuinely the family’s belief – beggar belief that in those circumstances, steps wouldn’t have been taken to inform those that would have been closest to her in the Berkshire area.”

Ben Davey (Senior Chartered Legal Executive, Dean Wilson Solicitors) who acts for the family states:

“Isobel’s case is unfortunately another tragic example of how different arms of the NHS do not properly integrate with each other. The day before her death Isobel visited her GP and expressed clear suicidal ideations. There were attempts to refer her to community mental health services, but these were not properly triaged, because Isobel went to school in a different health trust jurisdiction to the one where she lived with her parents. As a result, the referral was not actioned, and she took her own life the next day.

We sadly continue to see our young people let down by mental health services. There is a particular issue with transfer between CAMHS (Child Adolescent Mental Health Services), and adult services, when the patients have turned, or is close to turning, 18 years of age. In his evidence to the Inquest, one of the GPs involved in Isobel’s care stated that often 17 year olds will be rejected by CAMHS, because due to the length of the waiting list, by the time that the referral would have been processed many months later, the patient would have turned 18 years of age. This failing system leaves both patients and clinicians in limbo.”

Speak with our team for support through an inquest

The team at Dean Wilson Solicitors are specialist at guiding families through inquests. Ben Davey acted for the family in this matter under a no win no fee agreement. Please visit our inquest page or contact us today at 01273 249200 if you would like to speak with our team. If you need someone to talk to, call Samaritans free on 116 123 or visit samaritans.org