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A coroner has raised concerns around how mental health services in Essex assess GP referrals following the death of a 20-year-old woman who took a “substantial overdose” of propranolol.

Tia Birkitt died in the emergency department at the Princess Alexandra Hospital in Harlow on May 18, 2025, after taking an overdose of her prescribed propranolol at home.

Essex Live has reported that she was treated Child and Adolescent Mental Health Services (CAMHS) before being discharged in 2022, and that she then struggled to be seen by adult mental health services.

In a report to prevent future deaths, Stephen Simblet, assistant coroner for Essex, wrote: “There is a concern that arrangements for the consideration of referrals made by GP practices in Essex may not lead to acceptance by mental health services or adequate further treatment, or be fully understood in the referral process.”

Mr Simblet added: “There is a concern that patients with presentations such as autism and communication difficulties such as selective mutism may either not have those difficulties adequately considered in determining what further treatment or referral is to be provided, or may not have adequately explained to them or their families how such treatments or further referrals may actually be delivered in a manner that takes account of those difficulties.”

In its response to the coroner’s report, an interim chief executive of Essex Partnership University NHS Foundation Trust extended their condolences to Tia’s family and said: “The Trust remains committed to ensuring patients are directed to the right service, at the right time, with referral decisions made by qualified mental health professionals who have access to senior clinical, psychiatric, and multidisciplinary support.”

They added that improving the experience of neurodivergent service users is “a priority,” with a dedicated steering group working on this currently.

Related: RCPharm urges MHRA to review safety information for propranolol

Diazepam prescribing guidelines not followed, finds coroner after suicide inquest