Timothy Julian STEELE · Prevention of Future Deaths report

On 14th August 2020 I commenced an investigation into the death of Timothy Julian STEELE. The investigation concluded at the end of the inquest on 10th March 2021. The conclusion of the inquest was “HE TOOK HIS OWN LIFE”

Tim Steele was a 28 year old man with, effectively, a lifelong history of low mood and depression with suicidal ideation. He described his first suicide attempts as taking place before he was 10 years old. He was socially isolated and this was emphasised when he was furloughed from work and spending most of his time alone in his studio flat in Brighton. During 2020 he made five or six attempts to kill himself. Prior to that, he had been in the care of the Children and Adolescents Mental Health Service, he had an informal admission following suicidality in 2014. Had a further episode of treatment from 2017-2018 and finally came to the attention of Sussex Partnership Foundation Trust again in May 2020. He registered with a GP in Brighton on the 12th May 2020. The service he received from the GP practice was excellent. From the evidence I FIND that their processes served Tim appropriately until after his assessment on 11th June 2020. The Mental Health practitioner referred him to the East (Brighton) Assessment and Treatment Service following the assessment. He wrote an excellent letter to the GP and copied it to Tim. This explained what Tim could expect but tragically nothing happened. Tim's referral was lost. Tim waited for the expected input. By late on 6th August when asked how he feels, he replies "if anything it's making it worse because of how...... my head feels as a result". On 10th August he died at his home address.

See Record of Inquest

(1) Mr. Steele was lost to ATS follow up apparently due to inefficient processes and a failure to appreciate the urgent need to appoint a Lead Practitioner for him. In particular the focus and delivery of the Care Programme Approach (CPA) as set out in national guidance “Refocusing the CPA- Policy and Positive Practical Guidance” does not appear to have been followed.
(2) In addition Sussex Partnership Foundation Trust appears to take a fragmented approach to its policies. Business is conducted in one way in Brighton and in another way, for example, in East or West Sussex and yet patients could be in Sussex depending on availability. They would apparently be dealt with differently depending on their geographic location.
At Tim Steele’s Inquest it was clear that staff members were not aware o how matters would be dealt with in other parts of Sussex.