A teenager who died after taking too many painkillers was prescribed the tablets despite two recent overdoses of the same medication, an inquest heard.
Ellie Knight, 19, was given a monthly supply of the anti-inflammatory drug Nefopam to treat back pain by a GP who later admitted in retrospect that he “should have given her less”.
The animal lover overdosed on the pills a fortnight after receiving the prescription and suffered cardiac arrest and severe brain damage.
She was rushed to Margate's QEQM Hospital but tragically died three weeks later on January 9 this year.
His family has now questioned why he was given such a large quantity of pills within two months after three previous overdoses – two of them involving Nefopam.
Ellie Knight (pictured) received a month's supply of the anti-inflammatory drug Nefopam to manage her back pain from a GP who later admitted, in retrospect, that he “should have given her less”
An inquest into her death was told that Ellie had gone to Newington Road training in Ramsgate, Kent, on December 4 last year, complaining of back pain.
GP Dr Geoffrey Kimanje believed seizures suffered in a separate overdose just a week earlier had caused joint inflammation, and it was suspected she had hypermobility problems.
The hearing was told that Ellie's mother, Sarah Knight, was said to have been 'angry that the doctor had prescribed' a month's supply of the medication, as she had reportedly requested that her daughter not receive the medication.
However, Dr Kimanje told the coroner he was faced with a difficult decision and that he spoke to Ms Knight – who did not attend the inquest – before issuing the prescription.
The GP said he did not recall any opposition, adding that he even made an agreement with Ellie and Ms Knight that the teenager's medication would be administered by her mother.
He told the hearing: 'I thought Nefopam was the best option for anti-inflammatories [issues]. I thought about getting her something more restrictive in terms of needing a prescription.
'I think it's easy to say she should have taken fewer tablets, but I didn't want to obstruct her care.
'I took confidence [the family]; In hindsight, I should have given her less.
Despite the reported agreement, it was not clear how or why Ellie came to administer the medications herself, although there was no suggestion that her family was to blame.
When asked if there was anything he thought he should or could have done differently given the circumstances at the time, the family doctor said: 'I don't think so.'
Knight was rushed to Margate's QEQM Hospital but tragically died three weeks later on January 9 this year.
The inquest heard that Ellie admitted having had suicidal thoughts since the age of 11 and was in the care of mental health services.
Her family expressed concern that an alleged promise of what they thought would be daily home visits had not materialized, with Ellie only being visited once by mental health teams.
But Kirsty Wade, operational manager at Kent and Medway NHS and Social Care Partnership Trust (KMPT), said such an offer should not have been made and would not even have been possible in Ellie's case, due to the fact she often spirals into night when I was at home. visits do not take place.
It was explained that Ellie did not engage well with other mental health teams and the view at the time was that daily visits could have increased the risk of Ellie acting on the commands of “disparaging voices” in her head.
Mrs Wade said: 'It was quite a complex picture. She stayed up late at night and was poorly built, but there was evidence of futuristic thinking and planning.
“She was also reluctant to use service contact numbers for support as she didn't like burdening other people with her problems.
“The risks were low enough that we could manage them in the community, but she could still potentially need some extra support.
'She didn't seem to have any coping strategies for when she was stressed.'
In addition to the failure of expected home visits, it was explained that a psychiatric appointment had to be canceled due to Ellie being in hospital following one of her overdoses. She died before it could be reorganized.
Coroner Catherine Wood said Ellie had sought help after the three previous overdoses.
She said that at the time of the fourth day, December 18, it was unclear what Ellie's intentions were.
Her family expressed concern that a promise of what they thought would be daily home visits had not materialized, with Ellie only being visited once by mental health teams from Kent and Medway NHS and Social Care Partnership Trust (pictured)
Delivering a narrative conclusion at the hearing in Maidstone on Friday, she expressed her condolences to Ellie's family and explained why she could not rule her death a suicide.
“She was referred to a psychological treatment program which she unfortunately did not receive due to her death,” Ms Wood said.
'I can't say whether her being on this path would have changed the end result.
“We have no evidence to suggest she wanted to die. I have no proof that she didn't intend to die. We don’t know the facts – we weren’t there.
'[Dr Kimanje] gave the reasons for his prescription of Nefopam. I accept his evidence on this point. He also called Ellie's mother at the time of the appointment.
“While I accept the evidence we have heard, it may have been better to have a plan regarding medication in the risk assessment process as part of a risk assessment in mental health services.
'As coroners, we see many deaths of young people who die as a result of their own actions.
“It's something we see in this world more than any of us would like, but it's very difficult for staff in a mental health setting to assess the risks here as to what can be done.
'I note that there is work to be done in terms of risk assessment and that work has been carried out and there have been reorganisations of services.'
Ms Wood added that she would not be making a Prevention of Future Deaths Report as mental health teams are already undergoing changes to staff training and guidelines in response to recent events.
Ellie's parents believe she did not intend to take her own life and have previously said they wish she had accepted how much she was loved by everyone.
They said: 'We don't think she did it to end her life or to get to the point she got to. It was a cry for help, but we can't change anything.
'She had such a big heart and was loved by so many people – more than she knew. We told her a lot, but she just wouldn't accept it.
'Ellie suffered from depression, she had worries and that played a big part in what happened.'
