Amy Butcher: Coroner identifies “muddled and unclear system for the prescription of medication” and issues Prevention of Future Deaths report to the Secretary of State for Health & Social Care

13 December 2024

Amy Butcher was 27 years old when she died by suicide. She was under the care of the Norfolk and Suffolk NHS Foundation Trust Crisis Resolution and Home Treatment Team (‘CRHT’) at the time of her death.

Amy had been experiencing severe anxiety and suicidal ideation and made several requests to mental health services, as well as NHS 111 and her GP, for a prescription of pro re nata (‘PRN’) medication in order to manage anxiety crises in the days before her death.

HM Senior Coroner for Suffolk Nigel Parsley found that taking a PRN medication was one of the steps identified in Amy’s agreed crisis plan. However, her requests for Lorazepam, which had previously been effective in helping her to manage anxiety crises, were declined.

HM Senior Coroner Parsley found that, had Amy had access to Lorazepam as a PRN medication on the night before her death, it is more likely than not that her death would not have occurred. He concluded that Amy died by “suicide as the result of a deterioration in her mental health, exacerbated by an ineffective PRN medication prescription, which failed to resolve her heightened anxiety crisis when needed”.

Following submissions made on behalf of Amy’s father, HM Senior Coroner also issued a Prevention of Future Deaths (‘PFD’) report to the Secretary of State for Health and Social Care. The report addresses a number of issues of concern, including that “evidence heard at inquest identified a muddled and unclear system for the prescription of medication to someone in Amy’s situation.” The PFD report can be found here.

Media coverage of the case can be found here and here.

Lily Lewis of GCN’s Inquests and Inquiries team represented Amy’s father pro bono at the inquest into her death, instructed by Broudie Jackson Canter.