Gary Etherington · Prevention of Future Deaths report

On 15th May 2019, I opened an inquest into the death of Gary Etherington, who died on 30th November 2018 in his van in a car park in the borough of Greenwich (03191-18 MM). The inquest was concluded on 24th June 2020. The medical cause of death was: 1a Cardiac Arrythmia 1b Amitriptyline and Nortriptyline overdose. II Coronary Artery Disease. The conclusion as to the death was Suicide.

Mr Etherington was recorded in February 2019 as having antisocial personality traits and a long history of cocaine use. He was arrested in April 2018 for threats to his ex-wife, had a Mental Health Act assessment which did not secure her history about extreme mood changes, paranoid behaviour, auditory hallucinations and delusions, which were probably psychotic. His behaviour was then ascribed to substance misuse; it is also recorded that he denied using cocaine for 6 months. In July he was assessed by a Mental Health Trust who elicited a history of auditory hallucinations of two voices to end his life, thoughts about wanting to kill himself all of the time and an admission that his wife says that he sees people who are not there and talks to them. Protective factors from suicide were noted and he was discharged to his GP. He was provided with temporary accommodation and his wife and friend provided other accommodation and he then also slept in his van. He did not qualify for priority housing by the local authority. He went missing on 20th November. He had stolen his wife’s Amitriptyline and taken an overdose, and was found dead in his van.

The coroner found that there were two failures in medical care, namely

1. The failure to contact ████████ at the Mental Health Act assessment in April
2. The failure to take and consider the history of ████████ before discharge and to discharge to GP care, without proper consideration of the voices telling him to commit suicide, delusions of people being present, their cause and relation to drug misuse, or the risks to ████████, about which there was an inadequate plan communicated to the GP.

These would have amounted to neglect, had it not been for the fact that there was no causative link with the death.

1. The fact that the deceased was under a restriction order not to contact his ex-wife was cited as a reason that no contact was made by the professionals conducting the MHA assessment. This may raise some process issues but would not seem to be an obstacle to securing corroborative evidence and insight into possible psychosis, especially noting the deceased gave no indication that he opposed such a communication.

2. The witness evidence heard and records consulted give the impression that those professionals involved in his care had discounted his symptoms as non-psychotic, without adequate investigation, underestimated his suicidality and not addressed the concerns of the GP who referred him about his management, and to whom his care passed without any psychiatric follow up or support.

3. Neither failure was recognised or investigated by the Root Cause Analysis which was described as Level 2 Comprehensive and concluded that there were no problems in health care. The court regarded the RCA investigation as unreliable. That causes some concern as to whether the Trust is able to identify care problems in future.