Mr Philip Anthony Dean · Prevention of Future Deaths report

On Friday 16th August 2013 I commenced an investigation into the death of Mr Philip Anthony Dean, aged 65 years. The investigation concluded at the end of the inquest on 9th April 2014. The conclusion of the inquest was:

Medical Cause of Death

1 (a) Drowning.

How, when and where and in what circumstances the deceased came by his death:

Mr Philip Dean suffered with chronic depressive illness. From June 2013 until his death, he suffered an exacerbation of this illness and became suicidal. He was referred to the Home Treatment Team and had a short admission to Springfield Hospital between 9/8/2013 and 12/8/2013. On the 13/8/2013, he jumped from Battersea bridge into the River Thames. He was recovered from the water and resuscitated, but unfortunately could not be saved and was recognised as clinically life extinct at Chelsea and Westminster Hospital the same morning.

With hindsight his death at this time was potentially predictable and therefore preventable. The recognition of his suicidality may have been hampered by the lack of continuity in the secondary psychiatric care services.

Conclusion of the Coroner as to the death

He took his own life whilst suffering from depressive illness.

Whilst the HTT was caring for Mr Dean, he only saw the same person on 2 occasions. Mr Dean therefore had no opportunity to develop any meaningful therapeutic relationships with the HTT. This may be why Mr Dean chose not to share suicidal intent with the professional who saw him the evening before he took his own life, based upon information gained from Mr Dean’s family. The HTT has no system of designated worker to provide such continuity. Mr Dean had to be discharged from the HTT to allow referral to psychology services, leaving him with only a crisis line number in the interim, but no ongoing planned intervention.

His GP was the one NHS health care professional with whom he had ongoing contact and knew him best. On 9th August 2013, his GP arranged for police to attend Mr Dean and take him to hospital if necessary under a section 136, since Mr Dean was in a park with a knife and expressing active suicidal intent. This was on top of the 6th August describing to his GP a method of suicide in his contemplation that turned out to be how he took his life. On the same day, Mr Dean expressed no ideation to the HTT.

On 9th August, his GP also telephoned psychiatric liaison at St Georges and stated that in his view Mr Dean should be assessed for section. This was not recorded in his notes and further Mr Dean was not seen by anyone who could have performed such an assessment. Neither was this information passed to the psychiatrist who subsequently allowed him to go home on the 12th August 2013, who thus made this decision without the benefit of the opinion of the GP. Mr Dean had not seen by a doctor until the following day, despite the circumstances of his admission and then only by a junior SHO, who had no prior knowledge of Mr Dean and no access to the GP’s concerns. The SHO records in the note that his assessment was limited to clerking essentials only due to pressure of work.

The SUI into this death did not demonstrate insight into any of the pertinent issues and was thus inadequate and unhelpful

(1) That the HHT is not sufficiently funded to allow continuity of care and named designated workers.

(2)That discharge from the HTT is required before referral to psychology can be made, leaving patients without ongoing support in the interim.

(3) That liaison psychiatry does not record pertinent information such as GP recommends section, thus denying those coming after the benefit of the GP’s professional opinion.

(4) That such an extremely psychiatrically unwell patient does not have the benefit of assessment from a health care professional qualified to make recommendations for section at first instance, despite explicit referral for the same from the doctor who knows him best.

(5) That secondary care services both the HTT and Liaison Psychiatry appear under to be under-resourced especially in terms of medically qualified personnel, and that this apparent under-resource impacts on the ability of these services to make accurate assessments of patients.

(6) That The SUI report missed all matters in issue in this case.