A Suffolk coroner has written to the Secretary of State following the death of a “lovely and bubbly” young mechanic from Ipswich.

Gemima Christodoulou-Peace died at the age of 25 in July last year, having struggled with her mental health for many years, particularly in the final few months of her life.

A two day inquest into Miss Christodoulou-Peace’s death was held at Suffolk Coroners’ Court earlier this month and returned a narrative conclusion.

During the course of the inquest, it was heard that she had had a “very, very difficult childhood”, having been raised by her brother and grandmother before being taken in by social services.

Miss Christodoulou-Peace had previously attempted to end her life on three separate occasions, and suffered regularly from depression and anxiety, having been diagnosed with borderline personality disorder (BPD).  

Miss Christodoulou-Peace’s body was found at her home on July 31 last year. It is believed she died “on or about July 26”.

Picture of Gemima Christodoulou-Peace in 2016 when she was at One Sixth Form College training to become a mechanicPicture of Gemima Christodoulou-Peace in 2016 when she was at One Sixth Form College training to become a mechanic (Image: Newsquest)

Senior Coroner for Suffolk Nigel Parsley said at the inquest he would be writing a Prevention of Future Deaths report to the Health Secretary Wes Streeting MP regarding his concerns.

In the report he referenced the fact that Miss Christodoulou-Peace had been prescribed the drug montelukast, which carries the very rare side effect of suicidal thoughts.

“At present there is no single reference point which a treating clinician can access, to readily and quickly identify if a patient is on a prescribed medication which is known to increase suicidal behaviour in some patients,” Mr Parsley wrote.

He also pointed out the fact that at present, “only a limited number of calls” going into the Norfolk and Suffolk NHS Foundation Trust (NSFT) are being recorded.

This makes it more difficult for clinicians responding to the needs of a returning patient, if the colleague who originally spoke with them is absent or unable to provide details of their care.

Mr Parsley added that there is also no opportunity to review cases.

Finally, Mr Parsley referenced the delay in Miss Christodoulou-Peace’s care; she first reported a decline in her mental health in March 2023.

After twice contacting her GP and being assessed over the phone by mental health services on July 25, a risk assessment deemed her as an ‘Amber’ risk. A treatment assessment was booked for August 8, 14 days on from her death.

Mr Parsley urged Mr Streeting to take action in order to prevent future deaths from people in similar circumstances to Miss Christodoulou-Peace from occurring. The Health Secretary has until September 16 to respond.