Kevin Paul SUTTON · Prevention of Future Deaths report

On 3rd September 2012, I commenced an investigation into the death of Kevin Paul SUTTON deceased aged 57 years. The investigation concluded at the end of the Inquest on 14 November 2013. The Conclusion of the Inquest was that the deceased had met his death by suicide and the cause of death was:
1. Asphyxia
2. Huntington’s Disease

The deceased had first been referred to the Somerset Partnership NHS Foundation Trust towards the beginning of this century but the first entry recorded in your Trust records is in April 2005.

Over the ensuing years he was seen on a number of occasions by a Consultant Psychiatrist from your Trust due to his continuing depression but was then thought to be low suicidal risk as a result of his Huntington’s disease.

The deceased was later admitted to Rydon Ward, Cheddon Road , Taunton where he was discharged on the 19 June 2012 to the Willows at Bridgwater but was admitted to Musgrove Park Hospital on the 26 June as he was not eating or drinking.

On the 11 July 2012 he was discharged from Musgrove Park Hospital to Halcon House, Huish Close, Taunton, premises belonging to Somerset Care Limited from where on the 3 September he would take his own life.

During the Inquest evidence was given by the manager of Halcon House that no care plan had been prepared, and as a consequence they were not made aware of the real suicidal risk that they faced with the deceased.

Failure by the Trust to provide care plans.