Nigel Harper · Prevention of Future Deaths report

On 27 July 2022 I commenced an investigation and opened an inquest into the death of Nigel Harper. The investigation concluded at the end of the inquest on 15 May 2023.

The conclusion of the inquest was that Mr. Harper died as the result of suicide.

In answer to the questions “when, where and how did Mr. Harper come by his death?”, I recorded as follows:

“On 8.7.22 Nigel Harper, who had over the previous month been experiencing severe depression and anxiety, and living with thoughts of self-harm, took an intentional overdose of prescribed sedative and hypnotic medications. He was taken to Worcestershire Royal Hospital where, despite treatment, he continued to decline, and died on 23.7.22.”

Mr. Harper lived in Scotland, but in the period leading up to his death had been staying with his sister near Malvern. He had a lengthy mental health history, which included a recent inpatient admission to a psychiatric hospital in Edinburgh.

(1) On 4 July 2022 Mr. Harper attended the Emergency Department at Gloucester Royal Hospital, and was seen by a nurse from the Mental Health Liaison team there, who recorded that he was very anxious and distressed, and voicing ongoing thoughts of suicide. The nurse felt that Mr. Harper would benefit from a period of treatment under the care of the Home Treatment Team, and because Mr. Harper was living in Worcestershire at the time, and because it was now in the early hours of the following day, he called the Worcestershire Crisis Team to arrange that. The nurse concerned was under the impression that by making this phone call, and passing on Mr. Harper’s details to the Crisis Team, he was referring Mr. Harper’s case to them. He told the inquest that he was expecting mental health services in Worcestershire to arrange a further urgent assessment of Mr. Harper, and he therefore ensured that Mr. Harper was told to expect the Crisis Team to contact him to arrange a further assessment.
(2) The Clinical Lead for the Crisis Team in Worcestershire gave evidence to the inquest that whilst the Crisis Team did receive a request from the nurse at Gloucester that night, they interpreted it only as a request for further assessment ( but not an urgent one ), and not as a request that Mr. Harper be referred to the Home Treatment Team.
(3) In the event, an urgent assessment was not arranged, and Mr. Harper’s case was only considered by the Home Treatment Team in Worcestershire when his temporary GP in Worcestershire, out of further concern for Mr. Harper’s mental health, made a new and separate referral to them.
(4) I have concluded that the events described above arose out of a lack of understanding between the two NHS Trusts concerned ( Herefordshire & Worcestershire Health and Care NHS Trust ( HWCT ) and Gloucestershire Health and Care NHS Trust ( GHCT ) ) as to how each other’s mental health services are run – otherwise arrangements would have been made for Mr. Harper’s mental health to be assessed urgently, as was intended.
(5) If staff at HWCT and GHCT do not understand how to make urgent mental health referrals or requests for urgent mental health assessments to each other, there remains a risk that other deaths may occur in similar circumstances in the future.