Alexander Vitali Lyalyushko · Prevention of Future Deaths report

On 12 March 2023, I commenced an investigation into the death of Alexander Vitali Lyalyushko.

The investigation concluded at the end of the inquest on 15 March 2024.

The conclusion of the inquest was suicide.

Mr Lyalyushko took his own life by hanging, intending to end his life, on 2 January 2023. Mr Lyalyushko died at his home address where he lived alone.

My Lyalyushko was a vulnerable young man with diagnoses of autistic spectrum disorder, anxiety, depression and agoraphobia. Mr Lyalyushko was known to express suicidal ideation and had made suicide attempts. Mr Lyalyushko had extensive involvement with mental health services throughout his life, including with Gedling Local Mental Health Team under Nottinghamshire Healthcare NHS Foundation Trust from August 2015 to August 2019, and from July 2020 to March 2022.

A request for the involvement of Gedling Local Mental Health Team with Mr Lyalyushko was sent to the service by Mr Lyalyushko’s General Practitioner on 22 November 2022. For reasons which have not been ascertainable, no action was taken in response to that request. Mr Lyalyushko took his own life a little over a month later, there being no involvement of mental health services with him at the time of his death.

Detailed findings as to how Mr Lyalyushko came by his death are described within a written determination dated 15 March 2024, appended to this report

1. Inadequate review and incident investigation following a death

Following Mr Lyalyushko’s death, Nottinghamshire Healthcare NHS Foundation Trust completed an SI Review by way of case note review. Following evidence which considered the content of that review, the Trust stated that the review was ‘insufficient in its current form and the scope should be broadened to include the concerns raised (during the inquest hearing).’ The Trust said its Patient Safety Investigation Lead would undertake a new SI Review by 26 April 2024 (6 weeks).

I identified a number of deficiencies with the initial SI Review which had been undertaken in respect of Mr Lyalyushko: it did not identify that a request from Mr Lyalyushko’s GP in November 2022 for involvement of its service with Mr Lyalyushko had not been actioned; it incorrectly identified areas where improvements were required as areas of good practice; and it did not involve any level of consultation with Mr Lyalyushko’s family to consider whether there were any areas of concern they had which might direct elements of the review.

If there is insufficient review and learning from a death that, in my judgment, adds to the likelihood of future deaths occurring in similar circumstances.

I am not reassured that necessary actions to address the serious issue identified i.e. inadequate initial review and incident investigation following a death, are yet in place.