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The failure of a mental health trust to follow national prescribing guidelines for diazepam prescribing has been cited as a matter of concern in an inquest into the death by suicide of a 26-year-old Essex woman in 2022.

In a report to prevent future deaths, Essex area coroner Sonia Hayes found that Abbi Smith, who had autism and learning difficulties, had a history of repeated suicide attempts and had spent most of her adult life detained under the Mental Health Act, was put on a treatment regimen that had “not been previously successful” following a deterioration in her mental health in October 2021.

At the time, Abbi had become non-compliant with her clozapine regimen, to which she had previously had a “sustained positive response”.

Instead of following the advice of her consultant psychiatrist and NICE guidelines to temporarily prescribe diazepam to assist with “an exacerbation of distressing symptoms” and re-titrate clozapine, diazepam was continued as a “permanent prescription” in the absence of a medicines review and against NICE guidelines.

“Abbi remained on a medication regimen that was known not to work,” the coroner wrote, adding that “no plans were put in place” to mitigate this.

Abbi was discharged on February 14, 2022 to “mitigate a known significant risk” but this was done despite none of the three tests for discharge previously established by community mental health staff having been met. She was found dead in Braintree Recreation Ground the following night.

The coroner identified a number of other concerns arising from the case, including the fact she was treated by “very junior clinicians” despite being “an extremely complex patient,” her medical records not being updated as required, information sharing issues and a lack of staff training in how to communicate with autistic and neurodivergent patients.

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