Kirsty Jane Noblett’s family may never know exactly why she lost her life
A happy and loving mum who was making plans for the summer died after taking an overdose of prescription medication.
Tragically, Kirsty Jane Noblett will never know what her intentions were when she fatally ingested the drugs on June 15, the day after a very rare drinking session. A coroner on Tuesday (October 18) recorded a narrative conclusion as she said she could not be satisfied that Kirsty wanted to end her life.
The inquest heard “missed opportunities” meant the 33-year-old, who had a history of mental and physical health issues, was not linked up with additional services while receiving the support of the Chorley mental health team through Lancashire and South Cumbria NHS Foundation Trust (LSCFT). It was also heard that risk assessments and risk management was not at an “appropriate standard” within the overstretched teams.
The possibility that an increased dose of her prescribed medication may have increased her suicidal thoughts was also raised, the inquest heard. Kirsty had suffered with anxiety, depression and a borderline personality disorder in the past and had made an attempt on her life previously in 2020.
In the lead up to her death, she was considered by her partner, her family, and her care coordinator to be happier than in the past. She was in a relationship with Daniel Baxter, who was described at Preston Coroners Court as “the one” and was happy to have her children living together in a new home.
Days before her death, she visited her mum to take a birthday card and flowers and happily chatted about future plans including meals out and activities with the kids. Her sister described her as not being suicidal, with Mr Baxter observed she had never self-harmed in their relationship. But after a day spent with friends, she began to feel “down” and continued drinking into the early hours with them, something which she very rarely did.
When Mr Chadwick left their shared home to collect the car the next day, he returned to find her lying unconscious. She was taken to Royal Preston Hospital and admitted to the critical care unit but did not respond to medication.
In a statement summarised by assistant coroner Laura Cox, Kirsty’s sister Keira said she had been happy and chatty when they last saw each other on their mum’s birthday. She added that although Kirsty had been experienced suicidal thoughts before, she always said protecting her children was her motivation not to proceed. Keira added that she was an “amazing mother, daughter, sister and aunt”.
Marie Mason, Kirsty’s care coordinator, said that she was assessed as being low risk and was proactive in being involved in her own treatment. She had also been quick to contact the service whenever she felt her mental health was struggling and the fact she did not do so this time came as a shock. Although Kirsty had declined therapy in the past, she later agreed but was on a waiting list at the time of her death.
Briony McEwan, patient safety lead at LSCFT, carried out an investigation into Kirsty’s death as part of her responsibilities and said opportunities were missed during her treatment. This included examining her past more, linking up with services to help with parenting stresses and better understanding her risk management.
Ms McEwan explained that Kirsty, originally from Preston, had recently asked for an increased dose of her Fluoxetine medication but may not have been aware of a small and rare side effect which is an increase in suicidal thoughts. She said: “Although she had a past of contacting services for help, she might not have recognised that feeling was from the increased dose.”
She says the biggest challenge for mental health teams is stretched resources which means they often are only able to concentrate on the most serious and urgent cases. She explained that changes have already been put in place in a bid to prevent future deaths, and Ms Cox said she was satisfied that necessary action had been taken.
Delivering her conclusion, Ms Cox described Kirsty as a “resilient” woman who engaged with mental health services to battle depression and anxiety. She said her actions before her death were out of character but noted “she was going out for meals, planning activities with her children, planning for the summer.”
Ms Cox said the evidence was not sufficient to deliver a suicide conclusion before describing the risk assessments and risk measures seen in her care as “not at the appropriate standards”. She added: “I have heard that these issues have been addressed and am satisfied that this will not happen again.”
Ms Cox recorded a narrative conclusion which stated: “Kirsty Jane Noblett died on June 15 2022 at Royal Preston Hospital from a hypoxic brain injury which was caused by an overdose of prescription drugs and alcohol
“It is not possible to determine Kirsty’s intention in consuming the alcohol and prescription drugs.”
- 05:50, 19 OCT 2022