“I lost my daughter because she wasn’t given the anxiety medication she needed”

A young woman who took her own life after her mental health team refused to prescribe “effective” medication was treated like a “baby begging for sweets”, her father has said.

Amy Butcher, 27, from Lowestoft, Suffolk, died in May 2023 – four days after being admitted to A&E during an anxiety attack.

He was given a drug called lorazepam, which he found very effective, but after discharge, Norfolk and Suffolk NHS Foundation Trust (NSFT) refused an application for a new prescription. Instead, he was offered an “ineffective” alternative.

Following an inquest into her death last month, Suffolk Coroner Nigel Parsley warned that the way drugs are prescribed for people receiving mental health care could put others at risk.

In a Prevention of Future Deaths (PFD) report to Wes Streeting, Mr Parsley described the system as “confused and unclear” and urged the health secretary to take action.

He wrote: “Amy’s own GP gave evidence that the system was confusing.”

Mr Parsley highlighted Ms Butcher’s struggles to make changes to her medication – which involved her contacting her GP, NHS 111 and the out-of-hours GP service all told that her medication it doesn’t work.

However, on each occasion these services were unable to make changes or provide new prescriptions due to the involvement of the mental health team who had jurisdiction over her care.

Mr Parsley wrote: “There is clearly no single point of contact or decision-maker regarding prescriptions in these cases.

“Evidence suggests that the situation is further exacerbated if the deterioration of the individual’s mental health occurs out of hours.”

Mrs Butcher’s father John has now launched a civil action against the NSFT after the inquest found his daughter’s suicide could have been prevented had the trust not prescribed ineffective medication.

Speaking for the first time since the inquest, he said Paper i“I’m sure Amy would still be here if she had been given the medicine she so desperately needed. Amy had no lifelong history of mental illness.

“She had been suffering from insomnia and anxiety for around six months before she took her own life and I believe the way she was treated exacerbated her condition.

“My kind and bubbly daughter was catastrophically let down and made to feel like a nuisance. She felt like a burden because the system dehumanized her and acted like she was a child asking for more sweets.

“I understand how she felt because I felt anxious and frustrated when I called on her behalf. We weren’t helped, we were blocked.”

Mr Butcher, a plumber and heating engineer, described his daughter as having a “zest for life” before she was afflicted with insomnia and anxiety.

He said lorazepam calmed Ms Butcher “completely” after she arrived in a “terrible state” at the James Paget University Hospital last May. However, after discharge, she was unable to obtain more of the drug.

“To then be refused what you know will help you, which has previously been given by other NHS staff, has put Amy in such a desperate state,” Mr Butcher said.

“He had nowhere to turn. Being pushed from 111 to the GP back to the mental health team made her anxiety worse and once she was denied what she thought was her only life, she couldn’t see a way out.”

Ms Butcher’s GP described the system as having “too many chefs” after being blocked from prescribing the effective drug because of a system that allows mental health teams to make changes to a patient’s regime just once under their jurisdiction.

Kayleigh Littlemore, civil liberties lawyer at Broudie Jackson Canter, who represented the family through the inquest and now in the civil case, said: “The inquest into Amy’s death was a compelling exercise for my client. Mr. Butcher experienced first-hand the pain he was in and the barriers he repeatedly faced when trying to get help.

“We welcome the Preventing Future Deaths Report and will be keeping a close eye on how the trust addresses the issues raised by the coroner.

“The report and investigation show that there is a clear case of medical negligence to answer. Nothing will replace the void that Amy’s avoidable death has left in her family’s lives, but they are determined to take action to protect other families from experiencing the same life-changing loss.”

Mrs Butcher is the second child her father has lost after Butcher’s 21-month-old son Jordan died of a brain tumor in 1999.

“I know what it’s like to not be able to see in the dark. I was prescribed a drug similar to Lorazepam when I lost my son and I was rooted in grief,” he said.

“This recipe helped me gradually work my way through my pain to a place where I could stand up and face the world again. I just wish Amy had been given that opportunity.”

After an active social life in her teens and early 20s, Mrs Butcher had recently moved from a flat in Lowestoft to a house with a garden by the sea.

Mr Butcher, who also has a 10-year-old daughter, said: “Amy loved being out in nature and had such a passion for animals. He loved his dog and kept birds and fish.

“She worked all her life in pubs as a cook before securing a job as a driver delivering car parts across the country. It was a gas station so it was the ideal role for her and she loved it.

“She was in a happy relationship and had a fantastic group of friends around her. She was loved and full of life. It is common for people to suffer from mental health episodes during their lifetime. The difference is that Amy didn’t get the help she needed to get to the other side.

“I always envisioned Amy with my grandchildren in the not-too-distant future. Now that’s never going to happen and I’m left trying to make peace with it.”

The trust said it was progressing with its response to the coroner.

Anthony Deery, chief medical officer at NSFT, said: “We are very sorry for the distress the tragic loss of Amy has caused and we would like to offer our sincere condolences to her family.

“We are now carefully considering the Coroners Prevention of Future Deaths report so that we can make the necessary changes to ensure our services are safer, kinder and better in the future.”

A Department of Health and Social Care spokesman said: “Our deepest sympathies go out to Amy’s family and friends in this tragic case. Every patient deserves access to effective treatment.

“We are working to improve care for people with mental health needs. Our Mental Health Bill, currently before Parliament, will ensure that people with the most severe mental health conditions receive better, more personalised, appropriate, proportionate and compassionate treatment for their needs.

“We will also work with the NHS to transform care and recruit an additional 8,500 mental health workers from children’s and adult services to reduce delays and provide faster treatment.”

In the UK contact the Samaritans on 116 123 for 24/7 support or email [email protected]