Finding into death of Suzanne Berg

62y · Female·unascertained

Suzanne Berg, a 62-year-old woman with schizophrenia, died in her home between January and May 2013 with an unascertained cause. She had a long history of disengaging from treatment despite having medication-controlled diabetes, hypothyroidism, and significant mental illness. Her GP attempted appropriate engagement and monitoring, contacting mental health services when concerned about missed appointments. After Ms Berg's last documented well mental state in April 2011, she disengaged from care in September 2011. The coroner found no clinical mismanagement but highlighted the need for better guidance on assertive follow-up of mental health patients in primary care who voluntarily engage in treatment but then disengage without notice, particularly given GPs manage substantial psychological presentations.