Simon Jonathon Klemberg · Prevention of Future Deaths report

In June 2015 an investigation commenced into the death of 58 year old Simon Jonathon Klemberg. The investigation concluded at the end of the inquest on 19th May 2016. The conclusion of the inquest was that Mr Klemberg died from a self-inflicted, reckless and impulsive overdose of prescription medication, administered to address acute head pain, possibly caused by his psychological condition.

Jonathon suffered serious mental health problems for the last 18 months of his life and was diagnosed with agitated depression and generalised anxiety. Jonathon was hospitalized after near fatal self-harm incidents in May 2014 and November 2014 following which an extensive psychological assessment was conducted. Individual psychological therapy was recommended in February 2015, but was delayed due to waiting lists and never commenced. Psychological therapy may have reduced the risk of death in this case. It is not possible to say on the balance of probabilities whether Jonathon would have survived if he had been able to access individual psychological therapy.

During the course of his illness Jonathon developed increasingly severe intermittent head pains possibly rooted in his emotional and psychological condition. The pain Jonathon felt led to impulsive and reckless self-medication in an attempt to reduce that pain.

Reckless self-medication led to an overdose on 27th May 2015 and a further admission to hospital. Jonathon was discharged home the following day and referred for assessment to the Home Treatment Team (HTT) on the basis that he was considered to be a significant risk to himself. The function of the HTT is to provide intensive treatment or critical care to people in their own home who are in an acute mental crisis, without such support might require hospital admission.

The HTT assessed Jonathon on the 29th May 2015 and found him to be a high risk to himself. The HTT decided not take him onto their caseload or to admit him to a psychiatric unit. Jonathon was referred by the HTT to the integrated community mental health team.

Admission to hospital or support from HTT from 29/5 may have reduced the risk of death in this case. It is not possible to say on the balance of probabilities whether Jonathon would have survived if he had been taken onto the HTT caseload.

Before any further treatment could commence a further reckless overdose caused his death in the early hours of 7th June 2015.

(1) To review the availability of beds for psychiatric patients in Cornwall. Kernow Clinical Commissioning group (KCCG) to respond
(2) To review the allocation of resources to the home treatment team, with particular reference to the threshold for offering support. Both Kernow Clinical Commissioning group (KCCG) and Cornwall Partnership NHS Foundation Trust (CFT) to respond
(3) To review the waiting lists for individual psychological therapy. Cornwall Partnership NHS Foundation Trust (CFT) to respond.
(4) To review procedures for prioritizing high risk patients in waiting lists for psychological therapy. Cornwall Partnership NHS Foundation Trust (CFT) to respond.