Poonam Sachdeva: Inquest finds ‘missed opportunity’ to get help for mum after 10-year mental health battle
An inquest found a “missed opportunity” to get help for a beloved mum who took her own life after a 10-year mental health battle.
Poonam Sachdeva, aged 44, of Western Road, Crookes, died on March 4 at the Northern General Hospital after drowning at Ladybower reservoir.
She was found by her son and daughter after her husband, Vipin, noticed she was missing from home that morning.
Assistant Coroner Katy Dickinson heard evidence from Dr Harborne, a GP at Manchester Road surgery, where Mrs Sachdeva was a patient, about the last time she saw the mum-of-two.
Mrs Sachdeva first became known to mental health services in 2013.
She managed her schizophrenia by taking antipsychotics but had a relapse in symptoms before her death.
On February 29, Mrs Sachdeva contacted her GP surgery concerning her mental health.
Mrs Sachdeva saw Dr Harborne the same morning and she expressed a relapse in symptoms including hearing voices.
Dr Harborne said: “At the appointment she appeared calm and engaged well. She gave clear details about what was going on and had a good understanding of her mental illness.
“She did not speak about suicidal ideation and clarified that the voices were not telling her to hurt herself or others.
“We discussed a medication increase which would have a sedating effect. She asked for a two-week sick note and said it may be enough to make her better.
“We had a clear conversation about safety netting and clarified she had the crisis numbers. Her husband was supporting her and she knew she could attend A&E if her symptoms got worse.”
A plan to review the prescription was made for the next week.
The court heard Mrs Sachdeva’s mental health continued to deteriorate on March 1 and Mr Sachdeva attempted to get a crisis referral for her through Single Point of Access (SPA).
When he phoned SPA he was told his wife would need a GP referral to access the service.
He phoned the GP surgery the same day and told the receptionist his wife was in crisis.
He was told to fill out a form online as they could not help him over the phone.
Dr Pendlebury, a GP partner at Manchester Road surgery, gave evidence over a video link.
He said the surgery was in a “transition period” for patients who were used to phoning up for appointments.
He spoke of the surgery’s move towards a triaged system which means patients are asked to fill a form out either online, over the phone or in person with a receptionist.
Dr Pendlebury said: “An element of the phone call was not ideal. The receptionist could have made it clearer that Mr Sachdeva could contact the surgery again if he had any issues or she could fill out the form on his behalf.”
A ‘significant event’ analysis review was completed and a number of changes have since been made.
This includes a message being added to the surgery website informing patients they can contact the practice if they have any issues with the online form.
Staff at the surgery, including receptionists, must now also complete suicide training.
In a police statement Mr Sachdeva said that on March 4 he woke up at 6.30am to find his wife has not there.
He checked his Ring doorbell which showed her leaving the family home at 5.15am and getting into their car. He told the police his wife had previously referred to Ladybower Reservoir and his son and daughter went to see if she was there.
He stayed home to phone the police and waited for his children to come home.
Mrs Sachdeva’s body was found at the reservoir and she was taken to Northern General Hospital, where she sadly died.
Assistant Coroner Dickinson returned a conclusion of suicide.
She said: “There was a missed opportunity on March 1 when Mr Sachdeva contacted SPA. I can’t say whether things would be different had she had the assessment.”
A family pen portrait reads: “Our hearts ache because we see her everywhere. We feel her gentle touch on the cherry blossom which flourished just after her passing.
“She changed her whole career to work in the NHS just to be around people. She spread a smile and a spark to the whole ward of Royal Hallamshire hospital where she worked.
People couldn’t resist being attracted to her beautiful soul.
“Every step she took was a spring and a gallop and had the most beautiful smile in the world. She was the engine of our family.”
When life is difficult, Samaritans are here – day or night, 365 days a year. You can call them for free on 116 123, email them at [email protected], or visit www.samaritans.org to find your nearest branch.