Anthony Joseph McCormack · Prevention of Future Deaths report

On 17/05/2019 I commenced an investigation into the death of Anthony Joseph McCormack. The investigation concluded at the end of an inquest on 27th August 2019. The conclusion of the inquest was Suicide due unavailability of an inpatient mental health bed.

The Deceased was found dead at his home on the 7th May 2019 after family became concerned that he was not answering calls. The Deceased who suffered with paranoid schizophrenia had been identified as being in crisis on the 6th March 2019 and authorisation had been given to compel him to undergo inpatient treatment under section 2 of the Mental Health Act on the 16th March 2019. However, a bed was not available and he was managed by the home treatment team. The home treatment team were not in a position to adequately assess Mr. McCormack due to the nature of his underlying condition, this lead to an underestimation of his risk and he was taken off the waiting list for a bed on the 25th April 2019 and discharged from the home treatment team to the community mental health team on the 29th April 2019. Mr. McCormack was not reviewed again by mental health services despite a request from his family on the 7th May because they were concerned for his wellbeing. If Mr. McCormack had been admitted to hospital it is likely that on the 7th May 2019 he would have remained in hospital receiving more effective treatment than in the community and would not have ended his life.

Following a post mortem the Deceased’s treating clinicians the medical cause of death was determined to be:
1a) HANGING

1. Between the 16th March 2019 and the 25th April 2019, a bed could not be found for the Deceased even though he had been assessed and fit for detention. The absence of a bed meant that Mr. McCormack was not adequately assessed and appropriate treatment could not be given. With inpatient admission it is unlikely Mr. McCormack would have taken his life. The evidence from witnesses from BSMHT was that there continues to be a shortage of beds.
2. Evidence was given that the case load of the home treatment team to whom Mr. McCormack was referred is carrying 5 times the number of patients it was originally intended for and does not have the resources to provide adequate assessment and monitoring to patients thereby putting lives at risk.