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An NHS trust has implemented measures to avoid inappropriate long-term prescribing of benzodiazepines, following the death of a patient by suicide.
In a ‘Prevention of future deaths’ report, published online on 13 August 2026, coroner Sonia Hayes raised concerns with Essex Partnership University NHS Foundation Trust about its care of Abbigail Smith, aged 26 years, who died on 16 February 2022.
The coroner wrote that Smith had been detained under the Mental Health Act and was prescribed clozapine, to which she responded positively, “such that she was discharged to supported living as the attempts to end her life had ceased”.
In October 2021, Smith suffered a deterioration in her mental health with reported non-compliance of clozapine medication, the coroner said.
The coroner added that she was then given a short-term prescription of diazepam to assist with an exacerbation of distressing symptoms until clozapine could be re-titrated. However, this was “incorrectly continued as a permanent prescription in the absence of a medical review and this was not compliant with the NICE [National Institute for Health and Care Excellence] guidelines”, the coroner said.
In a response to the coroner’s report, published on 22 July 2026, Essex Partnership University NHS Foundation Trust accepted that the consultant psychiatrist’s emergency plan “was only partially followed during this period”.
“The consultant acted appropriately in October 2021 prescribing a carefully considered short-term bridging plan whilst awaiting clozapine recommencement and arranging a medical review for December 2021. However, the trust acknowledges that diazepam was converted from PRN [pro re nata] [as needed] to twice daily without clear documented medical authorisation and Abbi’s decision to decline,” it continued.
The trust added: “There is now an electronic patient medication system in place where clinicians are able to see the patient’s previous medical history in respect of previous hospital attendances and past medication reviews.
“There is now greater pharmacy input in place for inpatient services, with pharmacists now sitting in on MDTs [multidisciplinary teams] and supporting medication history reviews.”
David Taylor, director of pharmacy and pathology at South London and Maudsley NHS Foundation Trust, said that clozapine was often the only effective solution for some patients, and other drugs were often prescribed while clozapine could be re-titrated to an effective level.
“If there is any lesson to be learned it is that clozapine is the only treatment for people who have relapsed after stopping clozapine. It needs to be re-titrated as soon as possible,” he said.
The trust also said that since the incident, it has commissioned a trust-wide audit of benzodiazepine prescribing in the community “to provide assurance that all prescribing adheres to NICE guidelines and BNF [British National Formulary] guidance regarding indication, dosage, duration, and review, with findings informing quality improvement actions where required”.
Orla Macdonald, a consultant pharmacist for learning disabilities at Oxford Health NHS Foundation Trust, commented: “This is truly a tragic event, and I think it is important that all professionals reflect on what they can do to improve care and prevent events like this from happening.
“It seems to me that the crux of this issue is not about medicines, but rather about how we should communicate with each other; inpatient team to community team, community team to GP, GP to community/crisis teams about a person’s care and how we should communicate with someone who is autistic.”
The coroner noted that Smith had autism and a learning difficulty. Macdonald suggested that a ‘Learning from lives and deaths — people with a learning disability and autistic people’ review may identify some more appropriate findings to improve care for patients such as Smith.
Responding to the coroner’s report, the Essex Partnership University NHS Foundation Trust accepted “that greater consideration could have been given to how Abbi’s autism and learning disability influenced her communication needs, understanding of diagnosis and engagement with services”.
“Given the complexity of Abbi’s presentation and the recognised risk of deterioration, there should have been greater multidisciplinary oversight and more structured crisis planning to reduce the risk of hospital admission,” it added.
