A mum of four who told consultants she wanted to die before being discharged from a mental health crisis team was found dead in a lake days later.
Xiaokui Chen also known as Katy, of Sturmer Road, Bedford was reported missing in the early hours of April 4 by her family and was discovered by a dog walker at a lake near Thurne Way, North Brickhill. Police and paramedics attended but she was pronounced dead at 1.45pm the same day.
Coroner Tom Osborne told the inquest held at Ampthill Coroners Court Mrs Chen’s cause of death was drowning as a result of suicide.
Mrs Chen, 43, who had emigrated to the UK from China in 2003, settling in Bedford, complained in January of throbbing headaches. She suffered from nausea as the headaches became progressively worse, aggravated by loud noise and bright lights.
She had no prior history of migraines so was sent for an MRI scan and a benign tumour was found.
Mr Osborne said: “If nothing had been done she would have been paralysed then died.” The tumour was succesfully removed and there was no reason why she shouldn’t have made a full recovery.
But she visited her family GP Dr Tunde Ogunyiluka informing him she had problems sleeping since the operation.
Dr Ogunyiluka said: “I felt she was depressed,” adding it may have been due to the medication she was given after her surgery to reduce swelling.”
Mrs Chen, who the Coroner said “was not a fusser”, returned to see her GP telling Dr Ogunyiluka she started hearing voices, suggesting “psychosis rather than depression.”
She also asked him for an “injection which would kill her” explaining if he couldn’t help her die she would: “hang herself, stab herself with a pair of scissors or jump out of a window. She said she loved her family but needed to die.”
Dr Ogunyiluka immediately referred her to a mental health crisis team. Consultant pyschiatrist Dr Lalana Dissanayake, who saw her on April 2, said: “She spoke of hearing an angel’s voice saying ‘come to heaven’.”
Dr Dissanayake, when pressed by the Coroner as to why Mrs Chen was released from the unit on April 3, said: “She held my hand and said ‘no angels’ and hadn’t heard any more voices. I was shocked when I heard she took her life the next day. I couldn’t believe it. My foresight was wrong but I did the best I could. Looking back I was wrong.”
A second consultant pyschiatrist, Dr Thilaka Ratnayake who saw Mrs Chen, said he did not underestimate her condition but “anticipated more observation.” 24 hours after being discharged Mrs Chen was dead.
The Coroner said: “I find this case particularly tragic. There was an element of complacency by the two consultants not to apply foresight. She was discharged too soon in view of the serious matter of her depression and risk of suicide.”
Verdict: death by drowning as a result of suicide.