Stephen Anthony WARD · Prevention of Future Deaths report

On 06.03.14, I commenced an investigation into the death of Stephen Anthony Ward, aged 41 years. The investigation concluded at the end of the inquest yesterday. I made a determination that Stephen Ward took his own life by hanging.

Mr Ward had a long history of depression and other mental health problems, but he deteriorated in 2013, following the death of his mother at the hands of his step father, and his step father’s suicide by hanging.

Mr Ward had a great deal of input from a variety of mental health services, including daily visits/telephone calls from the South Camden Crisis Resolution Team in the period immediately leading up to his death.

When he did not attend the South Camden Recovery Centre at Jules Thorn, or respond to telephone messages or an unannounced crisis team visit on Thursday, 27 February (the day before he was found hanging by a close friend), members of the crisis team were worried.

They did not immediately ask police to conduct a welfare visit, which I appreciate was a matter of clinical judgement. They were influenced in particular by the fact that their visit was not scheduled and so he might have been out, as he had been on a previous occasion.

However, at around 7.30pm on Thursday, 27 February, a member of the crisis team placed a call to police asking for a welfare check to be carried out. What concerns me is that, when the police did not call back within an hour or two, nobody from the crisis team followed this up with the police.

The next contact was at around 8.15am on the morning of Friday, 28 February, when the police rang the crisis team to say that they were outside Mr Ward’s building and could not locate his flat.

In fact, Mr Ward’s friend had by this time found him hanging.

Mr Ward did not have any personal contact with anyone after Tuesday, 25 February, so by the time the alarm was raised on Thursday evening, he might well have already died. However, he might not. In any event, following up with the police might be critical for another person in his position.

It seems that the team would benefit from a clear protocol about the required action once police have been contacted and I invite you to consider this.