Anthony John Preston · Prevention of Future Deaths report

On 28 July 2014 I commenced an investigation into the death of Anthony John Preston. The investigation concluded at the end of the Inquest on 27th July 2016. The conclusion of the inquest was:

The Cause of death was:

1.a. Hanging

The Conclusion of the Coroner was:

Mr Preston killed himself

Mr Preston had been suffering from mental health problems for a short period in the summer and autumn of 2013. On the 17 October 2013 he was admitted to The Priory Hospital in Cheadle, and remained there as a voluntary patient until the 11 November 2013. He was under the care of ████████ in early November he was granted home leave for a few days. The leave was not successful and he returned early to the hospital. It was clear that home leave was a time of great stress to Mr Preston.

On the 11th November he was discharged to his home, and into the care of the Crisis Team in his home area of Leicestershire. ████████ gave evidence at the Inquest that the system upon discharge was for a nurse at the Priory to speak to a nurse in the Crisis team in Leicestershire, to send a fax to the GP indicating discharge and the medication prescribed, and it was to be followed up with a discharge letter.
There was no documentary proof of either the telephone call to the Crisis team, of any fax, and the only comment available was a discharge letter to the GP that was sent on the 27 November, two weeks after discharge. The Crisis team denied that they had received any notification, telephonic or otherwise, of Mr Preston’s discharge.

In consequence:
1. The Leicestershire Crisis Team were unaware of his discharge
2. Therefore, they did not arrange any follow up by the Crisis Team
3. After a few days at home Mr Preston became extremely anxious and depressed and ████████ had to contact a mental health professional to request that he see Mr Preston, which he did immediately, and arranged a Mental Health Assessment.
4. This resulted in Mr Preston being admitted to The Bradgate Unit in Leicester on the 15th November, 4 days after leaving The Priory.

In May 2014 Mr Preston hanged himself. It is not suggested that there is any causal connection between his death and the discharge arrangements from The Priory.

(1) Mr Preston had demonstrated, in his early return from home leave in the first few days of November, that living at home was a source of substantial stress, and likely to cause him severe anxiety and deepen his depression.
(2) The system for discharge of patients, whereby a nurse makes contact with (in this case) the Leicestershire Crisis Team does not appear to have been robust. There was no documentary proof of the telephone call.
(3) There was no immediate follow up by email or fax to the Crisis Team to notify the discharge, and the fact that Mr Preston was at high risk because of the anxiety created when he was living at home.
(4) As a result, Mr Preston and his main carer ████████ were left without support at a time when he was at high risk.