The death of a "kind" and "caring" young woman at a mental health unit in Bury was contributed to by "ineffective" policies in place at the time, an inquest jury have concluded.
Ania Sohail, 22, collapsed after ingesting medication she'd bought from online pharmacies whilst detained under the Mental Health Act at the Junction 17 unit in Prestwich.
Miss Sohail, who had been diagnosed with emotionally unstable personality disorder, and had a history of self-harm, was able to order medication from four different websites and had it delivered to her family's home in Whalley Range.
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The inquest heard she had been granted unaccompanied leave to visit her parents ahead of Father's Day, despite a previous overdose attempt less than two weeks earlier.
Despite being subject to a bag and hair search on arrival back to the unit on the afternoon of June 18, 2021, she was able to sneak the medication into room her at the site, Rochdale Coroner's Court previously heard.
She suffered a cardiac arrest after consuming the medication the following day, and was transferred to North Manchester General Hospital where she tragically died.
A jury concluded that Miss Sohail died as a result of suicide with intent, which was contributed to by "ineffective" searches carried out by the unit, which is run by Greater Manchester Mental Health Trust (GMMH). They found that the search on June 18, in particular, contributed to her death.
Her death was also contributed to by 'inadequate post leave assessment' and the 'omission of safety plans' which reflected the risks posed to Ania on June 18, the jury found.
They also concluded that a lack of an integrated national system, which could be accessed by online pharmacies for dispensing medication, a lack of access to GP records, and a lack of consent to sharing information, contributed to Miss Sohail's death.
The inquest previously heard that Ania had ordered doses of the medication, which the M.E.N is not naming, from a number of different online pharmacies.
Mohammed Yasir, a pharmacist at one of these websites, told jurors that patients were asked a number of questions about their medical backgrounds before being issued medication. In response to a question on whether she had ever been diagnosed with a mental health condition, Mr Yasir said Ania claimed she had not.
She also refused to give consent for her request to be shared with her GP. Despite this, the pharmacy issued Ania with three separate prescriptions between March and June 2021 - all of which were sent to her family's home address.
Nur-E-Fardous Choudhury, a remote prescriber for a different pharmacy, said he was not aware that Ania was an inpatient on a mental health unit when he issued her medication on two separate occasions - in April and June of 2021.
Had he known that Ania had a mental health condition, or that she had been given medication by other online pharmacies around the same time, he said neither order would have been accepted. When issuing Ania a second, larger dose on June 14, Mr Choudhury said he was not aware that she had previously overdosed on the medication.
Assistant Coroner for Manchester North, Catherine McKenna, said she would be writing to the Secretary of State for Health to share her concerns about the lack of information sharing between online pharmacies.
"The relevant providers gave evidence that they would not have dispensed medication had they been aware she was making requests to several other online pharmacies," Ms McKenna said.
"I also have concerns that information given by Miss Sohail to the providers was taken at face value. They gave evidence that they would not have dispensed the medication if they knew of her mental health condition and that she was sectioned under the mental health act.
"I do have concerns about medication being dispensed without the knowledge of the GP and I will be writing to the Secretary of State for health asking for action to be taken."
Ms McKenna said she would also be writing to the Chief Executive of GMMH about concerns raised over the recovery and discharge plan in place at the Junction 17 unit at the time of Miss Sohail's death.
Bosses at the trust apologised to Miss Sohail's family "wholeheartedly" for the areas of care which they said 'fell well below the highest standards we strive for.'
Ania, originally from Berkshire, moved to Whalley Range with her family when she enrolled on a course at the University of Manchester in 2019 following a gap year.
Her mum Leena said Ania was an "intelligent" young woman but had suffered mental health issues since around the age of 12, and previously attempted to take her own life around the time of her GCSEs and A-levels. Ania again suffered with her mental health in February 2020, following exams.
After periods in Salford, Wythenshawe and North Manchester General hospitals, in June 2020 following an overdose attempt, she was moved to the Griffin Ward at Junction 17, an eight-bed ward for people aged 18 to 25.
Ania had been diagnosed with emotionally unstable personality disorder, which led to 'impulsivity', while she had also suffered 'depressive episodes,’ the inquest heard.
Consultant psychiatrist Dr Matthew Sanderson told the inquest he believed the Griffin Ward was not the right place for Ania, but the court heard other units were not able to meet her needs. Ania had been a voluntary patient, but she was detained under the Mental Health Act in September 2020 following an overdose attempt, and this was renewed six months later.
Despite taking an overdose on March 10, 2021, restrictions weren’t placed on Ania’s unaccompanied leave or internet usage, the court heard. Ania had taken an overdose on June 5 after telling staff how she ‘wanted to die,’ but was allowed to go on leave for the day again on June 18.
The inquest heard how the Grifiin Unit had the 'lowest level of security' and the searches carried out by staff were 'limited'. Dr Sanderson explained how 'therapeutic risk taking' was part of the treatment, with an emphasis on the need to trust inpatients on the Griffin Ward.
A bag search was conducted on Miss Sohail's return to the ward on June 18, the inquest heard, while her hair was also searched, but no medication was found.
Mental health nurse Lauren Parry began her shift shortly after Ania's return, and told the inquest there were 'no concerns' about her, with her 'mood lifting' during the course of a 'pleasant evening'.
On the following day, Ania had collapsed in the dining area of the Griffin Ward. A nurse asked if she had taken anything, to which Ania replied 'sorry', and boxes of medication were found in her room.
Having been found unresponsive by paramedics and gone into cardiac arrest, attempts to resuscitate Ania were eventually stopped at North Manchester General Hospital, and she was pronounced dead at 3.36pm.
Following a search of Ania's room, Greater Manchester Police discovered notes at her bedside table, including one dated June 19, 2021. GMP also discovered payments to four different online pharmacies in her bank statements, while Ania had searched about 'suicide' online 10 days before her death.
Dr Naomi Carter, pathologist at Royal Oldham Hospital, gave the medical cause of Ania's death as toxicity caused by the drug she had taken.
The inquest heard that Ania was a 'kind-hearted' and 'funny' young woman, and a gifted artist. "Nobody can be in any doubt that she will be sorely missed by her friends and family," Ms Mckenna said following the conclusion.
Within the same nine months of Ania's death, two other patients at the mental health unit also died. Charlie Millers, 17, died in December 2020 and Rowan Thompson, 18, died in October 2020.
Greater Manchester Mental Health NHS Foundation Trust, which was placed into the 'equivalent of special measures' last year, have been asked to commission and 'external report' into the three deaths.
A spokesperson for Greater Manchester Mental Health NHS Foundation Trust said: “We express our deepest sympathies to Ania’s family and all who cared for her.
“We note the findings of the Coroner, and apologise wholeheartedly for the areas of care which fell below the highest standards we strive for. Since the tragic incident, we have carried out a series of actions to improve patient safety. However, we recognise there is more to be done, and we will action this as a highest priority.
“It would be inappropriate to comment further until we have properly considered and responded to the Coroner’s request under Regulation 28 (PFD).”
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