A coroner has criticised an NHS Trust and GP surgery after a woman fell to her death from The Exchange shopping centre car park.
Maureen Campbell-Scott climbed over the wall of the multi-storey car park in Ilford and lay on a ledge 50 feet up on June 16 last year.
When a member of the public and staff from the High Road shopping mall tried to help her she appeared to roll off the narrow ledge.
At an inquest into her death in March east London senior coroner Nadia Persaud ruled that she died from multiple injuries.
She said Mrs Campbell-Scott died as a result of her own actions but there was no evidence to suggest she meant to end her life.
Ms Persaud issued a prevention of future deaths report following the inquest listing six concerns about communication between Mrs Campbell-Scott’s GP surgery, Fullwell Cross Medical Centre in Tomswood Hill, Barkingside, and the North East London Foundation Trust (NELFT).
It reveals that Mrs Campbell-Scott’s doctor referred her to the wrong team at the trust when her mental health deteriorated in April 2016.
The referral was then lost, leading to a four month delay before she was seen by the trust’s staff.
The report highlights two-week long delays between the trust sending letters requesting medication changes and her doctor receiving them.
It adds her GP failed to follow the trust’s psychiatric team’s directions over her medication.
The report states Mrs Campbell-Scott had seven prescription changes between November 2016 and February 2017.
“It is challenging for GPs to be able to ensure rapid and accurate changes when medication changes are directed by the specialist team,” the report notes.
The report implies neither the trust nor surgery learnt from mistakes at the time of the inquest about the best ways to improve communication.
The coroner ends saying the issue is unlikely to affect only Fullwell Cross surgery.
Mrs Campbell-Scott’s son Andrew said: “My mum was one of the most lovely, kind and thoughtful people you could wish to meet.
“Her family and friends have been devastated by her loss and firmly believe she would still be with us today if mistakes had not been made by NELFT and Fullwell Cross Medical Centre.”
A NELFT spokesman said the trust has developed a regularly reviewed action plan with the surgery and is working towards putting it into practice to tackle the issues.
Fullwell Cross Medical Centre was contacted but did not send a response.
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