Richard Patrick Carlon · Prevention of Future Deaths report

On 21/12/2018 I commenced an investigation into the death of Richard Patrick Carlon. The investigation concluded at the end of an inquest on 22nd July 2019. The conclusion of the inquest was Suicide.

The deceased had suffered from paranoid schizophrenia for many years and had been under the care of the Home Treatment Team receiving biweekly depot injections. He had a history of relapsing when taking illicit substances namely crack cocaine, cannabis and heroin. He did not engage with the MH team in October 2018. On 13/11/18 he attended Birmingham Heartlands Hospital emergency department with a relapse of his condition due to taking crack cocaine. He remained in the department overnight and following assessment at 10.10 on 14.11.18, when he appeared calm and insightful of what had happened, he was discharged to the care of the home treatment team. At 19.35 on 14/11/18 the deceased called WMP saying he would kill himself. Officers attended his mother’s address and detained him under S136 of the Mental Health Act and took him to a place of safety where he was assessed and admitted as a voluntary patient. On the morning of 15/11/18 the deceased asked to go for a cigarette. He did not wait for a doctor’s assessment so was escorted by a member of staff. He ran away from the member of staff who caught up with him however he stated he wished to leave but would return at 20.00. Mental Health notified WMP that he was absent but no log was created. At 15.09 the deceased’s mother rang to report him missing and officers were dispatched to investigate. There was confusion around whether he was in fact missing. At 21.07 he was found safe and well at his father’s home where he remained overnight. On 16/11/18 he remained at his father house leaving and returning several times. He last left at 21.30 saying he was going to see a friend. At 22.15 on 16/11/18 the deceased was seen on a lorry webcam to step in front of the lorry travelling along the A45 Coventry Road. He was taken to QE hospital emergency department where he was noted to have multiple injuries including a severe head injury. He was admitted to ITU and subsequently died on 14/12/18.

Based on information from the Deceased’s treating clinicians the medical cause of death was determined to be:
POLYTRAUMA
ROAD TRAFFIC COLLISION

1. No approved Mental Health practitioner was available to make the Mental Health Act assessment of Mr Carlon on 14/11/18. I was told this was an ongoing problem and was delaying assessments.

2. When Mr Carlon was found safe and well at home WMP did not advise BSMHT. This was a missed opportunity for Mental health to re-engage with Mr Carlon and make a further assessment of his condition. Consideration need to be given to how agencies can improve communication.