Delays in getting critical care may have contributed to woman’s suicide, report says
By Charlotte Lillywhite, Local Democracy Reporter
A mum with severe postnatal depression took her own life after waiting nearly two months to be put on a waiting list to see an NHS psychiatrist.
Judith Obholzer had been advised to admit herself to a private hospital the day before she died in July last year, but could not because of financial constraints.
In a prevention of future deaths report, Ellie Oakley, assistant coroner for Inner West London, said delays in Ms Obholzer’s care may have contributed to her death. An inquest found she died as a result of suicide on July 12 last year, following a ‘significant period of worsening depressive illness’.
The report found there were delays by South West London and St George’s Mental Health NHS Trust in assessing Ms Obholzer and adding her to the waiting list for a full assessment by a consultant psychiatrist. It said a private psychiatrist who she visited the day before she died could not directly access crisis support for her.
A trust spokesman said providing timely care to patients is its highest priority and it is ‘deeply sorry’ for falling short of that in Ms Obholzer’s case. A Department of Health and Social Care (DHSC) spokesman pledged to fix the ‘broken’ mental health system so that patients get the care they deserve.
Ms Obholzer had been suffering from depression and anxiety since at least March 2023. Her GP had prescribed her antidepressants and she started seeing a private practitioner weekly for cognitive behavioural treatment on March 12.
Her GP referred her to the Wandsworth single point of access (SPA) team, which manages patient referrals to mental health services, on May 15 and she was assessed by a triage nurse on May 18. However, she was not put on the waiting list for an assessment by a consultant psychiatrist until July 10. During this time, she was experiencing thoughts of suicide and planning.
Ms Obholzer attended a consultation with a private consultant psychiatrist on July 11 due to the decline in her condition and the wait for NHS care. The psychiatrist diagnosed her with severe postnatal depression and found she was at significant risk of suicide.
The psychiatrist recommended Ms Obholzer admit herself to a private hospital, according to the report, but she was against this due to financial concerns.
The psychiatrist later gave evidence that he was not able to refer patients directly to NHS crisis teams as a direct alternative to voluntary treatment at a private hospital. The report said that while the trust provided evidence that direct referrals could be made, the exact procedure for this was unclear.
The coroner sent the report to the trust, NHS England and DHSC after raising concerns that ‘future deaths will occur unless action is taken’.
The report said: “In the course of the evidence it was confirmed that there is significant pressure on NHS mental health services. It seems likely that there will be an increase in patients obtaining private support while waiting for NHS support (and often only being able to afford such support for a limited time and to a limited extent and doing so only while waiting for NHS support), as happened in this case.”
A South West London and St George’s Mental Health NHS Trust spokesman said: “We extend our heartfelt condolences to Ms Obholzer’s loved ones. Providing timely care to our patients is our highest priority, and we are deeply sorry that we fell short of that on this occasion. Since then, we have completed a full investigation and taken several actions to reduce delays for patients needing an urgent assessment
A DHSC spokesperson added: “It is important that we learn the lessons from every prevention of future deaths report and the department will consider the report carefully before responding in due course.
“People with mental health issues are not getting the support or care they deserve, which is why we will fix the broken system to ensure we give mental health the same attention and focus as physical health.”
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