Young doctor 'fell between the cracks' of mental health system, inquest finds

The death of a young doctor ‘who touched the lives of many’ was a tragic example of someone who ‘fell between the cracks’ of the mental health system, a coroner has concluded.

Dr Jaipreet Panesar, better known as Jai, was from Burnham and worked as a GP in High Wycombe. She died aged 36 in April last year.

Jai was found in a Maidenhead hotel and her death was determined to be a suicide. An inquest into her death took place at Reading Town Hall this week.

In the year leading up to this point, Jai was ‘severely anxious and depressed’ after a series of personal misfortunes.

Jai went through ‘ill-fated’ jaw surgery that left her in chronic pain, making it difficult for her to eat, sleep and talk. Her marriage had also broken down.

She moved out of her family home and began staying at friends’ homes, ‘sofa surfing’ and sleeping in her car. Her whereabouts was unknown on multiple occasions, making her family ‘desperately worried.’

Struggling over a long period of time, Jai made several attempts to get help. She took herself to A&E on the advice of her doctor, voluntarily checked in to a psychiatric ward, went to private therapy and was taking antidepressants for a time.

Jai told various health professionals that she was thinking about ending her life and mentioned she had updated her will.

Looking back, her family felt that professional assessments of Jai were ‘woefully inadequate’ and that the teams had not fully appreciated Jai’s ability to mask the extent of her illness.

They said they were ‘dumbfounded’ by the actions of police and other parties, who they felt had ‘absolved themselves of their responsibilities.’

In the events running up to Jai’s death, her doctors were ‘quite concerned’ about her, said Dr Durgesh Rajsingh, GP partner at Burnham Health Centre, at the inquest.

But there were limits to what they could do – they were not always able to contact her.

One doctor attempted to refer her to The Crisis Team – specialist staff including nurses and psychiatrists who support people in acute mental distress.

But the team felt the referral was ‘inappropriate’ because these concerns were coming to them ‘third hand’ and the doctor had not been able to speak to Jai himself.

The doctor, Dr Daily, was ‘a bit panicked’, when he contacted them, the team noted.

Representing Jai’s family, barrister Remi Reichhold asked if that alone should not have given The Crisis Team ‘pause for thought.’

The inquest heard it was the team’s understanding that Jai could be referred to them once Dr Daily had spoken to her – but there may have been some crossed wires, with this taken as a ‘rejection’ of the referral.

Moreover, the problem remained that it had been difficult to assess Jai, as her engagement with various support bodies had been on and off.

But senior coroner for Berkshire, Heidi Connor, stressed that Jai had in fact engaged ‘quite a bit’.

She queried whether Jai should have not been offered longer term support and better coordination of care.

Representatives from Oxford Health NHS Foundation Trust, which runs The Crisis Team, agreed that was something that ‘should have been considered.’

They also acknowledged ‘gaps in record keeping’ that made it difficult to answer certain questions at the inquest. These notes did not explain why The Crisis Team did not make a face-to-face visit to Jai after they discharged her.

Mr Reichhold said the way in which the team deals with referrals and follow-ups was a central concern of Jai’s family.

Summing up, Mrs Connor said she had to decide if these events contributed ‘more than minimally’ to Jai’s death, and concluded that she was unable to ascertain this.

She highlighted Jai’s deterioration ‘over a period of years’ and likened it to other cases where patients had ‘fallen through the cracks.’

Mrs Connor will be making official recommendations for further action in due course. One thing to consider is how communication can be improved between various mental healthcare bodies.

In a family statement, Jai’s father, Taran Panesar, described his daughter as an ‘intelligent, multi-talented’ woman who excelled academically from a young age.

He said she ‘fought against the depression but eventually ‘it had all become too much,’ leading to her decision to end her life – which would ‘give her the peace she so desperately sought.’

“She brought kindness and peace to strangers who need it,” he said. “She touched the lives of so many.”

A note from The Samaritans: Whatever you are going through, you don’t have to face it alone. Call Samaritans for free on 116 123, email jo@samaritans.org or visit www.samaritans.org for more information.