A leading neurologist who treated the Dorset teenager Gaia Pope has told an inquest jury there was a “failure of communication” within the NHS, after revealing he was not informed her mental health had declined shortly before she died.
Matthew Walker, a professor of neurology at University College London, accepted that a chance to review Pope’s care when she was taken to hospital after a psychiatric episode a few weeks before her death was missed because the hospital did not contact him.
He told the jury in Bournemouth that electronic health records were not always compatible and GP surgeries, which used to operate as a useful information hub, were too stretched.
Asked by the senior coroner for Dorset, Rachael Griffin, if better communication could prevent future deaths, he said: “There is a general lack of communication throughout the NHS.” Later he repeated: “There is generally a failure of communication within the NHS.”
Pope, 19, is believed to have died of hypothermia on a clifftop after disappearing from Swanage and may have been experiencing an epileptic seizure or mental health episode at the time, the jury has heard.
The teenager was diagnosed with post-traumatic stress disorder (PTSD) after reporting being raped at the age of 16. For the first time on Tuesday, the jury heard she was allegedly drugged with ketamine before being sexually assaulted.
Walker said he first saw Pope on 15 March 2017. She told him she had five to 10 seizures daily that induced a feeling of intense fear. She also had “tonic clonic” seizures, which often involve a person falling unconscious.
Walker told the inquest Pope’s epilepsy was complex and he began exploring the possibility of her undergoing surgery but between July and her death in November 2017 neither Walker nor the epilepsy nurses he worked with spoke to Pope.
The coroner said the lack of contact “concerned her”. Walker said he “assumed” she was still in contact with local epilepsy services. Griffin told the doctor: “It is dangerous to assume things.”
Walker said mental health issues can exacerbate epilepsy but he told the jury he did not hear that in October 2017 – the month before her death – Pope had been taken to hospital and underwent an assessment to decide if she should be detained under the Mental Health Act. He said he would have liked to have been contacted by the hospital and, if he had been, would have reviewed Pope’s care.
Asked by the coroner if this was a “missed opportunity” to look again at her care, Walker replied: “Absolutely.”
He said organisations had different electronic records, which were not always compatible. Walker also said GPs had been “useful hub” through which different teams could communicate, but this had eroded over the past decade. “They don’t have the time or resources. There has been a failure of that system.”
The consultant psychiatrist, Dr Dinesh Kannan, said he diagnosed Pope with PTSD after she told him she had flashbacks to her alleged rape and experienced “hyper-vigilance”, always scanning for danger.
Kannan decided to refer her to a service called Steps2Wellbeing, but omitted to send the referral letter. Admitting this was an error, he said: “I should have checked … The letter didn’t go through.”
Pope was sectioned under the Mental Health Act in February 2017 after her alleged rapist tried to make contact. She suffered a severe seizure and spent eight days in hospital, but was discharged without Kannan or his colleagues speaking to neurologists who were working with Pope for her epilepsy.
Kannan agreed it would have been “good practice” to do this. “That was a missed opportunity,” Kannan said. “We should have liaised. The communication could have been much better.”
The inquest continues.
In the UK and Ireland, Samaritans can be contacted on 116 123 or email jo@samaritans.org or jo@samaritans.ie. In the US, the National Suicide Prevention Lifeline is 1-800-273-8255. In Australia, the crisis support service Lifeline is 13 11 14. Other international helplines can be found at www.befrienders.org.
