Benjamin James HART · Prevention of Future Deaths report

On 17th October 2022 an investigation was commenced into the death of Benjamin James HART. The investigation concluded at the end of the inquest 28th March 2023. The conclusion of the inquest was a short form conclusion of Suicide
1a Suspension by the neck
b
c
II

Benjamin Hart, 25 had a medical diagnosis of post-traumatic stress disorder, enduring personality change after a catastrophic experience, emotionally unstable personality disorder borderline type and generalised anxiety disorder. He likely had Asperger's syndrome. At the time of his death was under the care of the community mental health team following a suicide attempt by hanging in December 2021 following which he was formally sectioned. After his release he was allocated a care coordinator who between May 2022 and his death in October 2022 saw him on only three occasions (his care plan envisaging weekly involvement). The Trust was aware that the relationship between Ben and his care coordinator had broken down but a new care coordinator was not appointed and Ben had no contact from the community mental health team for 5 weeks before his death on 12th October 2023 when he hanged himself at his mother’s home address. He had telephoned the Crisis team three times in the two days before his death, calls which included complaints of having been abandoned by the mental health team, expressions of hopelessness about his future and indications that he felt suicidal. He was informed that the community mental health team would contact him. Although the community mental health team and the care coordinator were notified of Ben’s calls the day before his death, no one attempted contact until after this death had occurred. Kent & Medway NHS partnership Trust accepted at the inquest that the care provided to Ben fell below the standard he could have expected to receive and there were missed opportunities to treat him

The Trust had a shortfall of nursing staff in the Dover and Deal area at the time that Benjamin Hart was under the community mental health team such that although 16 nurses were required to run the service, the Trust only had 8 nurses employed at the time, 2 of whom were long term sick. This left a working complement of 6 nurses to cover the whole area, which required them to take on additional duties. There was no resilience within the team and therefore when the relationship between Ben and his care coordinator broke down there was no capacity within the team to allocate him another care coordinator.

Although the Trust has regrouped, reorganised and there has been some limited recruitment the shortfall endures; the evidence given at the inquest being that this is a national issue but it is particularly difficult to recruit within this area of Kent