Ania Sohail was a 22-year-old student who died at the North Manchester General Hospital on June 19 2021.
A record of inquest, seen by C+D, found that Ms Sohail died by suicide following a medicine “overdose”.
The report said that she was able to obtain “numerous prescriptions” of a beta-blocking medication from “multiple online pharmacies” prior to her death.
The Greater Manchester North District coroner overseeing Ms Sohail’s case flagged that there was “no integrated system of records” between the online pharmacies to track what had been dispensed by each of them.
Events preceding Ms Sohail’s death
Ms Sohail was an inpatient at Junction 17, a specialist mental health service in Manchester for young people requiring treatment for complex mental health difficulties, the report said.
She had been “diagnosed with an emotionally unstable personality disorder” and had a history of “self-harming behaviours”, it added.
After returning from home leave on June 18, Ms Sohail “suddenly collapsed” at lunchtime the next day and was taken to Manchester General Hospital, where she died later that day, it said.
An inquest into Ms Sohail’s death was opened in July 2021 and concluded last week (January 30), following a hearing attended by a jury at the Rochdale Coroner’s Court on January 16 this year.
Coroner’s findings
Coroner Catherine McKenna wrote in the inquest report that "prior to her death, Miss Sohail had been able to access multiple online pharmacies from 10 May 2020 to 15 June 2021, through which she obtained numerous prescriptions.”
“There was no integrated system of records which could be accessed by these pharmacies,” she added, saying that “the result was that the different pharmacies were not able to see what had been dispensed by the others”.
Ms McKenna further noted that Ms Sohail “did not disclose her relevant history, including her mental health history” to the online pharmacies when obtaining the prescriptions, and did not “provide her consent to share information with her general practitioner”.
The report concluded that “the death was contributed to by the ineffectiveness” of searches conducted by Junction 17 staff – which “did not reveal the presence of [the] tablets” – “inadequate post-leave assessment and the omission of safety plans which reflect the risks posed” to the patient.
However, it added that “in respect of the online pharmacies, there was a lack of integrated system or records which could be accessed by multiple pharmacies, lack of access to the GP summary care records… and lack of consent to the sharing of information”.
C+D has contacted Junction 17 for comment.
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