Sean Kay · Prevention of Future Deaths report

On 28th February 2020 I commenced an investigation into the death of Sean Kay, 50 years of age. The investigation concluded at the end of the inquest on 3rd November 2020. The conclusion of the inquest was one of suicide. The medical cause of death was (1a) drowning; 1b) Zipiclone and morphine intake.

Sean Kay had been suffering from mental health problems, including anxiety disorder, insomnia and (latterly) depression for some years. He received medication for his anxiety and low mood from his GP but to limited beneficial effect. In December 2019 he was referred by his GP to the mental health services of the Norfolk & Suffolk NHS Foundation Trust. Mr Kay was referred to the Early Intervention in Psychosis Team (EIPT) who, after assessment, determined he did not meet the criteria for first episode of psychosis. As a consequence, EIPT planned to encourage him to continue to work with the (primary care) Wellbeing Services (WBS) with whom he had contact from January 2020.

However, because of the added complexity that Sean had been identified by the EIPT as being in the ‘at risk mental state’ (ARMS) cohort of patients, he was deemed to be too complex for the WBS, by the WBS. An 'Interface Team Meeting' involving (amongst others) the WBS and the EIPT, scheduled for the 20th February 2020, to discuss the future care provision for Mr Kay, did not take place due to an administrative error and Mr Kay was not discussed at the meeting as planned. Consequently, at the time of his death six days later, Mr Kay was awaiting confirmation of whether – and/or from whom - he would be receiving support for his on-going mental health concerns.

On 26th February 2020 Mr Kay's body was recovered from an area of water near Stonea Bridge on Sixteen Foot Bank, Stonea. Life was confirmed extinct at the scene. Mr Kay had taken his own life whilst the balance of his mind was disturbed.

The evidence clearly identified a gap in service provision in the Norfolk and Waveney area for the cohort of patients into which Sean fitted.

Although having been identified as ARMS by the EIPT in Norfolk and Waveney, Sean nonetheless did not fit the strict criteria for accessing that service as he was deemed to have not yet suffered a first episode of psychosis; however his level of risk was sufficiently high that he was also considered unsuitable for WBS. Additionally, the evidence confirmed that Sean did not fit the criteria of either the Community Mental Health Team, the Crisis Team or MIND.

In contrast, in the neighbouring Suffolk area (and the evidence suggested in many other areas of the country) ARMS patients are recognised as falling under the commissioned EIPT umbrella and therefore receive commissioned assessment, treatment and management from that team.

This lacunae in service provision in Norfolk and Waveney meant that, at the time of his death, Sean fell between services and did not receive any appropriate care. In my opinion the continuation of such a lacunae in commissioned service provision gives rise to the risk of future deaths.