Edward Arthur Lundy · Prevention of Future Deaths report

On 24/08/2016 I commenced an investigation into the death of Edward Arthur Lundy, 23 . The investigation concluded at the end of the inquest on 05/12/2017. The conclusion of the inquest was “Suicide. During the course of diagnosis and treatment Edward Lundy was not seen by a psychiatrist, care options were not documented and discussed with family members and he was seen by numerous different health care professionals”. I recorded that on 23rd August 2017 West Combe Farm, Huish Champflower Edward Lundy deliberately suspended himself by the neck with the intention of ending his life.

Edward had a history of depression. He had been staying with a friend's family and was last seen alive when he went for a walk at about 10:00 hours on 23.08.16. The friend's mother went looking for him and found him hanging by the neck from a rope secured to a beam in a barn in a field on the family farm. He had secured wrists together in front of him with a cable tie. A note was also discovered at scene with his rucksack and a sports bottle containing alcohol. He was cut down and given CPR whilst an ambulance was called but could not be revived.

The South London and Maudsley NHS Foundation Trust (‘The Trust’) completed it's own Mental Health Investigation Report under the NHS England Serious Incident Framework. The investigation was conducted by ████████ Consultant Liaison Psychiatrist, St Thomas' Hospital and ████████ Team Leader for Lewisham PMIC Treatment Service. The Report acknowledges that Edward Lundy was known to the Trust since the 15th July 2016 being reported initially to Lambeth Assessment and Liaison Team and then to the Lambeth Living Well Network Hub where Edward was seen twice on 10th and 18th August 2016. Lambeth Hub contacted Wandsworth IAPT with a view to requesting that psychological therapy be re-started and an appointment was made for 24th August 2016.

The Trusts own findings identified a number of issues and a number of proposed actions.

1. Edward Lundy had contact with many professionals in a short period of time and that affected the continuity of his care. Proposed action to set up joint services review with provider organisations involved with an oversight report to be produced.

2. That upon Edward Lundy's discharge into the care of his family, there should have been independent consultation with the family and this should have been documented with the risks being explicitly discussed. Proposed action to ensure that the Psychiatric Liaison Operational Policy stated as such and to disseminate to all liaison teams via pathway meetings and local business meetings.

3. That the doctor referring Edward to the Lambeth Assessment and Liaison Team should have made it clear that he believed Edward should be seen by a psychiatrist. Proposed action that the Training Lead in the Trust be informed that GP trainees should receive risk management training, focussing on crisis intervention services e.g. when to consider CMHT/Home Treatment Team/Inpatient Admission.

There has been no evidence produced as to compliance with the recommended actions.

There has been no evidence produced as to the findings of the report and its proposed actions being started nationally so as to inform other Mental Health Trusts.

That the family received no information as to the proposed actions having been followed through and any resultant changes in procedure.