Thomas Josef Green · Prevention of Future Deaths report

On the 29ᵗʰ November 2016 I concluded the Inquest into the death of Thomas Josef Green date of birth 1ˢᵗ November 1994 who died on the 10ᵗʰ June 2016 at his home address in Denton, Tameside Manchester.

I recorded the deceased had a complex background. He had been assaulted in 2011 and also involved in a road traffic collision. These together with other life events were felt to have led to a diagnosis of post traumatic stress disorder.

The medical cause of death was confirmed as 1a) Asphyxiation secondary to hanging

Conclusion – Deceased had taken his own life

The Inquest into the death of Thomas Green had heard evidence that in August 2011 at the age of 16 he was assaulted. Following this he had difficulties leaving the house and became more isolated. On the first occasion he ventured out he was involved in a road traffic collision whereby as a pedestrian he was hit by a motor vehicle which didn’t stop, sustaining injuries to his head and legs.

The Court heard that following this the deceaseds behaviour and personality totally changed. He was a virtual recluse, over time he became violent towards family members, he became paranoid and had mood swings. In September 2014 he was referred to the Early Intervention Team as he had expressed both suicidal and homicidal thoughts. Throughout October 2014 his violent behaviour escalated towards family members and on the 13ᵗʰ November 2014 he was sectioned under Section 2 Mental Health Act. He remained an inpatient under the care of ████████ from the 13.11.14 until the 5.12.14. During his admission he was diagnosed with Post traumatic Stress Disorder.

Despite his inpatient status he was referred by ████████ on the 20ᵗʰ November 2014 to General Adult Psychiatry due to his “mixed personality disorder with paranoid and antisocial traits.” It was unclear what happened with this referral but it was noted, as stated that this referral was made whilst Mr Green was an inpatient.

Whilst an inpatient Mr Green was also diagnosed as having a pineal tumour.

On his discharge from hospital Mr Green was placed under the Home treatment team. He remained under the Home Treatment team until 1ˢᵗ April 2015 at which stage he was discharged back to his GP.

On his discharge from hospital there was no follow-up by a Consultant Psychiatrist nor was there any referral for treatment for his diagnosis of Post traumatic stress disorder.

In July 2015 his GP made a referral to Tameside and Glossop Healthy Minds for one to one CBT. He had his first assessment on the 26ᵗʰ October 2015 at which stage he had a PHQ 9 score of 25 and a GAD score of 17. Due to difficulties attending and sporadic contact Mr Green was discharged from the Service.

A further referral was made by his GP in May 2016 and the deceased was on a waiting list at the time he died.

Pennine Care NHS Trust, Churchgate Surgery and Tameside and Glossop CCG

1. It was unclear why a referral was made to Adult General Psychiatry whilst Mr Green remained an inpatient, there was no evidence that this referral was ever considered or actioned.
2. Hence when Mr Green was discharged from hospital there was no psychiatric follow-up and no treatment plan in place to address the diagnosis of complex PTSD.
3. When a referral was made this was made to Healthy Minds. The Court heard evidence how this was not a case which was suitable for Healthy Minds as it was complex and involved potentially complex PTSD.
4. The Court heard evidence that the referral document completed by the GP was not particularly detailed and therefore the complexity of the case was not apparent and the case was accepted.
5. The Court heard evidence that there is a commissioning gap for the provision of services for Complex PTSD and complex presentations such as that of Mr Green.