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Investigation and inquest
On Monday 25th July 2016 I commenced an investigation into the death of John Atkinson, 60. The investigation concluded at the end of the inquest on Tuesday 29 November 2016. The conclusion of the inquest was Suicide by Hanging.
Circumstances of the death
Mr Atkinson contacted the Mental health Team in July 2014 in crisis. Thereafter he received regular input from the psychiatric services until the time of his death. Input was provided by the Home Treatment Team, the Community Intensive Therapies Team and a brief period as an in-patient. A thread running throughout the treatment was a lack of effective communication between staff members and indeed with the family in terms of progression of Mr Atkinson’s illness which had been diagnosed as depression and anxiety with psychotic symptoms. Furthermore, there were key events of significant self harm attempts which were not escalated by the care co-ordinator finally. Finally when the care co-ordinator left, there were no measure in place to provide Mr Atkinson with an alternative care co-ordinator or indeed to even inform him or his family that the care co-ordinator was no longer with the Trust. At the time of Mr Atkinson’s final assessment by the psychiatrist six days before he passed away, a discussion with the family was lacking in detail and information and furthermore though the view taken was that there was an indication to involve the Home Treatment Team, due to a change in emphasis and seemingly an increasingly high threshold, accessing the Home Treatment Team had become extremely challenging and thus the referral was not made.
Coroner’s concerns
(1) Lack of updated Risk Assessments when key events occurred or there was a significant deterioration in presentation.
(2) Failure of the care co-ordinator to identify changes in presentation and level of risk and to seek a doctors input.
(3) Absence of an effective and robust system to identify and then manage patients under the care of departing staff (for example care co-ordinator).
(4) Lack of effective communication between mental health professionals at differing levels and also between those professionals and the patient and the patient’s family.
(5) Difficulty in consultant psychiatrists accessing Home Treatment Team Services when they considered a need (since a change in emphasis in interpreting the guidelines from the end of 2014).
Information checked against the published report and official responses