A coroner has criticised a GP surgery and a health trust after a woman with mental health difficulties took her own life.

Cricket Green Medical Practice, on Miles Road, Mitcham, and St George's Mental Health NHS Trust, based in Tooting, were criticised for not working together closely enough prior to the the death of Gillian O’Keeffe aged 50.

Angela Hodes, assistant coroner for Inner West London Crown Court, said in a report that the decision by St George’s to discharge her ‘for non-engagement’ was “illogical” when she was “in the greatest need of their help”.

Mrs O’Keeffe, who was prescribed antipsychotic medicine quetiapine to treat her schizoaffective disorder, was found dead in her home, the address of which hasn't been made public, on March 19.

An inquest last month found that "she took her own life while her balance of mind was disturbed”.

The 50-year-old was said to be a long-standing service user whose mental health had been deteriorating, and contact with professionals was said to be limited despite concerns raised by family members in October last year.

Ms Hodes added: “In view of her history and the inability of the trust or the GP surgery to make contact with Mrs O’Keeffe, it was highly unlikely that she would self-refer.

“There was no pre-discharge multidisciplinary meeting to include and inform the GP before discharge, nor attempt to ensure that there was a seamless transition to the GP surgery.

“Evidence was given at the inquest that there was no procedure or policy in place at the trust to follow up GP concerns or referrals, particularly where there was likely to be a degree of urgency.”

The assistant coroner noted that there “appeared no easy or appropriate way” her family could share information and their concerns about her mental state with a professional team, and felt professionals were “unaware” of her mental state despite their attempts.

Dr Mark Potter, medical director for South West London and St George’s Mental Health NHS Trust, said: “We are very sorry to the family of Mrs O’Keeffe for their tragic loss. We are carefully reviewing the coroners’ findings and the concerns raised by the family.

“We have already taken immediate action including reviewing our communication and shared care planning with GP’s and other agencies involved as well as strengthening our policy around when a client may not engage with services.

“We have listened throughout the inquest and as a result of the coroner findings, the concerns raised by Mrs O’Keeffe’s family and our own investigations we are focused on several areas.

“This includes enhanced multi-disciplinary meetings with GPs and other agencies, improving ways to involve families and reviewing relevant policies and procedures.

“The trust takes such learning extremely seriously and our dedicated staff will continue to do their best to support people at their most vulnerable.”

A spokesman for Merton Clinical Commissioning Group (CCG), which is in charge of local GP surgeries, said: "Our thoughts are with the family of Mrs O’Keeffe. Patient safety and care is always our primary concern and we are working with South West London St George’s Mental Health Trust to ensure that the recommendations identified are fully implemented to better ensure vulnerable patients are able to be supported.”