George Kenneth Fraser · Prevention of Future Deaths report

On 27 November 2024 I commenced an investigation into the death of George Kenneth Fraser, aged 37 years old. The investigation concluded at the end of the inquest on 14 May 2025. The conclusion of the inquest was an open inquest, as the cause of Mr Fraser’s death was uncertain.

Mr. Fraser was a 37-year-old gentleman who had suffered schizophrenia, hypothyroidism and misuse of alcohol. He required admission to a mental health hospital under a section of the Mental Health Act from 20 February 2024 to 18 March 2024. On discharge, he received very regular input from the Home Treatment Team until 9 May 2024, when he was transferred to the Mental Health & Wellbeing Team. There was no clear care plan in place whilst he was under the care of the Mental Health & Wellbeing Team. A new Care Co-Ordinator was allocated on the 5 June 2024. This Care Co-Ordinator met with Mr. Fraser on only one occasion (19 June 2024). Mr Fraser did not converse with the care co-ordinator at this time, so a meaningful risk assessment could not be completed. The last recorded contact with Mr. Fraser by the NHS services was an administrative call on the 9 July 2024. Family last had contact with him on the 8 July 2024. Visits were made by the mental health and wellbeing team on 16 July 2024, 22 July 2024 and the 24 July 2024 but there was no response. The family were informed that Mr. Fraser was "denying entry". The team did not make it clear to the family that they had received no response at all from Mr. Fraser - either to home visits or telephone calls. The mental health team did not notify the family that a friend had also raised concerns about a lack of contact with Mr Fraser on the 18 July 2024. When a further failed visit occurred on the 29 July 2024, the mental health and wellbeing team requested that the family assist them in gaining access to Mr. Fraser. Mr. Fraser's sister attended his home address and found him clearly deceased within the premises. A paramedic attended and pronounced his life extinct on scene. Police attended and deemed the circumstances as non-suspicious. A post-mortem examination was carried out. Despite a post-mortem examination, which included specialist tests for toxicology and neuropathology, a cause of death could not be identified. The pathologist considered that Mr. Fraser had likely passed away a few weeks before he was found. There was a lack of clear risk assessment, risk management and care planning by the Mental Health and Wellbeing Team, but it is not possible to reach a conclusion about the causal effect of this, as both the date when Mr Fraser passed away and the cause of death are unascertained.

(1) There was no clear and documented care plan in place whilst Mr Fraser was under the care of the Mental Health and Wellness Team. There was a lack of structure to the care provided to Mr Fraser by the Mental Health and Wellness Team.
(2) There was no robust risk assessment carried out by the Mental Health and Wellness team.
(3) The Mental Health and Wellness Team had been unable to reach Mr Fraser from the 16 July 2024. On the 18 July 2024 a friend contacted the mental health team to raise concern about his lack of contact with Mr Fraser. No action was taken at this time to review the risk of harm to Mr Fraser or to determine whether the Trust’s missing person procedure should be activated. There was no meaningful contact with the family to report the concerning lack of contact with Mr Fraser, until the 29 July 2024.