Harry David HALL · Prevention of Future Deaths report

On 1 June 2023 I commenced an investigation into the death of Harry David HALL. The investigation concluded at the end of the inquest on 30 April 2024. The conclusion of the inquest was Suicide

1a Intracranial Bleed

1b

1c

II

Harry David Hall had a history of depression, mental health illness and had expressed recent suicidal ideation. In the period leading up to his death he had been researching various websites relating to suicide.

He was under the care of the West Northumberland Community Treatment Team and no in person assessment had taken place prior to his death.

At approximately 16.30 hours on 29 May 2023 in the rear garden of Croydon Cottage Thorngrafton Hexham Northumberland he was found with a self-inflicted traumatic head injury the result of the firing of a captive bolt gun that he had recently purchased

(1) The deceased was seen by his General Practitioner on 27 March 2023 when he described ongoing suicidal ideation. His General Practitioner referred him to the 24-hour crisis team at 17.56 hours on 27 March 2023. The Initial Response Team ("IRT") provides 24 hour access to urgent mental health care and treatment. The IRT called the deceased at 22.37hrs on 27 March 2023 and I am told during which no immediate risks of self-harm were identified and although frequent thoughts of suicide were being experienced they were felt to be chronic in nature. The clinical decision was to not to refer on the Crisis Team and instead refer to the West Northumberland Community Treatment Team. There were two letters the first dated 31 March 2023 offering an appointment on 17 May 2023 and the second dated 4 April offering an appointment on 26 June 2023. I heard there was a ten week delay in appointments although that delay has since been rectified. The appointment on 17 May 2023 did not go ahead. No evidence was given as to why the appointment on the 17 May 2023 did not go ahead. There is nothing in the records, it is unclear if any assessment was undertaken at that time and this is crucial information. It is speculation if the outcome would have been any different if the deceased had been seen prior to his death. I am concerned with regard to the record keeping at this time.