Daniel David Rennoldson · Prevention of Future Deaths report

On 17th November 2020 I commenced an Investigation into the death of Daniel David Rennoldson (Daniel), who was born on 10th July 1993 and died at ████████ Greenfinch Road in Houghton-le-Spring on 11th November 2020 aged 27 years.

The Investigation concluded at the end of the Inquest on 16th June 2021. The conclusion of the Inquest was Suicide, the medical cause of death being: -
Ia Pressure on the Neck
Ib Hanging
II Ethanol Toxicity

Daniel died at 33 Greenfinch Road, Houghton le Spring on 11th November 2020 following a recent contact with mental health services.

The day before his death Daniel had been referred by the police to the street triage team after he had expressed suicidal intentions. Daniel was signposted back to his GP.

At 03:47am on 11th November 2020 Daniel made a telephone contact with the initial response team for 24 minutes. A face to face meeting with the assessment team was thought to be appropriate, but that team were already engaged. Daniel had indicated that he wished to sleep so the meeting was to be deferred. The initial response team finished their shift at 08:00am. At 10:30am the Crisis Clinician attempted to telephone Daniel but had no response, so left a message. Daniel lived within the catchment area of another crisis team, who were contacted at 11:37am. That team attended Daniel’s home address at 15:15hrs to learn that Daniel had died and communicated the fact of death to the original team at 17:55hrs.

Daniel had contacted the police at 04:18am to state that he was going to end his life. The police attended his home address at 04:28am to discover that Daniel had died.

Although the Trust had produced an Action Plan dealing with certain matters, in view of the evidence at the hearing the adequacy of the Action Plan should be reviewed together with the additional concerns, which emerged, namely:
1) there appeared to be no contingency to deal with more than one face to face response at a time, leaving other callers potentially at risk;
2) almost 12 hours had elapsed from Daniel’s call to someone visiting his home address with no mechanism to identify cases, which had not been progressed.