Teen GB sailor killed herself after medics’ computer system failed to flag her previous problems
Harriet Philo Powell had tried to seek help for her devastating depression after death of a close friend
A TALENTED teen sailor killed herself two weeks after taking an overdose because medics' computer system failed to show her previous calls for help.
Harriet Philo Powell was found hanging by her horrified dad Gordon Powell at their home in February.
The 18-year-old, who had qualified for the GB sailing squad when she was 11, had been battling devastating depression for many months following the recent death of a close friend.
She was also struggling with flashbacks from seeing someone having a heart attack and tensions at home about attending college.
The troubled teen had self-referred to the Norfolk and Suffolk Foundation NHS Trust (NSFT) in December and told staff in a phone assessment she had self-harmed and had suicidal thoughts.
But Harriet was not given an appointment until weeks later on February 22.
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The Colchester Sixth Form student was actually seen by mental health trust workers at West Suffolk Hospital, Bury St Edmunds, on February 11 after taking an overdose.
But staff assessing her could not see records from her previous contact with the trust as they were from different teams and on separate computer systems.
Harriet was discharged from the hospital the same day, but despite seeing a private therapist took her life a fortnight later.
A solicitor for Miss Philo Powell's family branded the issue "a systemic failing" after the tragedy while the Essex senior coroner said there were "weaknesses" in the process.
The NSFT said changes had already been made and lessons learnt from the incident, an inquest this week heard.
The inquest also heard from her private therapist who said there was "no indication" to suggest a risk to herself or others.
The talented guitarist was discovered dead by her devastated father in the barn at their home in Bulmer, on the Suffolk/Essex border, on February 25.
Last night Harriet's heartbroken mum, Ruth Philo, who attended the inquest with her husband, said: "She was due to have an interview the day after she died about her university course.
"Harriet was a beautiful, bright, warm, generous and talented young woman.
"She had a bright future and enjoyed an active life, including painting, sailing, dancing and playing guitar.
"Sadly Harriet was suffering from a severe depression that had lasted for 15 months and was ineffectively treated by antidepressants."
Harriet was studying A-levels in Art, Art History and English at Colchester Sixth Form College, after attending Hedingham School, and had secured a place to study Art at Oxford Brookes University.
She worked in the Sudbury Waitrose store at weekends.
Harriet was a beautiful, bright, warm, generous and talented young woman.
Ruth Philo
A keen sailor who had qualified for the British youth squad at age 11, she was also a sailing instructor at Abberton Reservoir, near Colchester.
At an inquest this week, Caroline Beasley-Murray, Essex senior coroner, concluded Harriet took her own life.
Mrs Beasley-Murray said: "I didn't have the privilege of knowing her but the impression I got is she was very intelligent, articulate, gifted all-rounder.
"I am sure she took a deliberate action knowing it would intend in her death.
"There were some weaknesses in the care provided by NSFT.
"The court is pleased the trust has set its mind to drafting an action plan, but there's far more to it than drafting a plan."
She said she would write a Prevention of Future Deaths report, and requested an update within three months from the NSFT about how its action plan had been implemented.
What changes have been made since Harriet's tragic death?
Michael Seaman is a service manager at NSFT who oversees the second team who assessed Miss Philo Powell and was involved in the serious incident review following her death.
Mr Seaman told the court several changes had now been made.
These include allowing all members of mental health teams to access both IT systems to read patients' records.
"Greater consideration should have been given to more viewpoints," he said.
Other worries raised by her family included that the assessment carried out at hospital involved a mental health nurse and social worker but no doctor - a fact they were not aware of until they were given a copy of the Serious Incident Report.
They were also concerned that a letter sent by NSFT to Miss Philo Powell's GP did not explicitly ask the doctor to review her medication, despite that being an outcome of the assessment.
The NSFT said these issues were being addressed with training, name badges for staff including their titles, and a new template for GP letters.
The NSFT has been criticised in the last year for high death rates and its financial deficit.
Its overall rating by the Care Quality Commission (CQC) is inadequate.
But the last inspection report into the trust was published in February 2015.
The trust is in special measures as a result of the CQC findings.
Alison Armstrong, director of operations for Suffolk at the NSFT, said: "This is a sad loss of a young life and our thoughts are very much with the family of Harriet Philo Powell.
"We have met with her parents to offer our most sincere condolences and listen to their concerns.
"Miss Philo Powell was appropriately assessed on February 11 by members of the psychiatric liaison service proved by NSFT at West Suffolk Hospital.
"Harriet's parents also confirmed they would seek therapy privately."
She added: "The make-up of the multi-disciplinary psychiatric liaison team is in line with national practice and the members of that team have numerous care pathways onto which they can refer should an assessment identify such a need.
"We take all deaths seriously and a thorough investigation has been carried out which has identified a number of points of learning.
"As a result our trust is implementing a number of changes to improve our services."
The inquest heard police attended the scene but ruled the death was not suspicious.
This is a sad loss of a young life and our thoughts are very much with the family of Harriet Philo Powell.
Alison Armstrong
No suicide note was found in the barn or in Harriet's room.
A toxicology report found some levels of alcohol and prescription medication in her blood, but not at excessive levels.
Lisa O'Dwyer, medico-legal director at Action Against Medical Accidents, which represented Harriet's parents, said: "Harriet's death is yet another example of a young person whose life has been cut short as a result of mental illness.
"This case and others like it demonstrate how a lack of basic, core skills such as communication, information sharing and planning can contribute to tragic outcomes."
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