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Investigation and inquest
On 28/03/2017 I commenced an investigation into the death of William John Callis whose date of birth was 19/02/1954. The investigation concluded at the end of the inquest on 07/03/2018. The medical cause of death was:-
1a) Hanging
Circumstances of the death
William John Callis was suffering from depression and sought help from his GP surgery in this regard.
████████ made an urgent referral to the Crisis Team on 10/02/2017 and he was seen that afternoon.
He was later reviewed by the Mental Health team.
He later was discharged from the urgent care and assessment team on 20/02/2017.
On 14/03/2017 he was seen by Advanced Nurse Practitioner ████████ at the GP surgery. His depression and anxiety symptoms were raised so ████████ referred him back to the Mental Health Team. This referral was not taken on.
William John Callis later hung himself at his home address on 28/03/2017.
Coroner’s concerns
1) During the inquest it became clear that there was no specific instruction as to the correct procedure for a GP practice to adopt when making a referral to the Urgent Care and Assessment team.
Information checked against the published report and official responses