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Investigation and inquest
On 13th February 2014 I commenced an investigation into the death of Mark Hancock dob 25.09.1971. The investigation concluded on the 27th October and the conclusion was one that the deceased had taken his own life. The medical cause of death was recorded as 1a) Multiple Incised Wounds
Circumstances of the death
I heard evidence that the deceased had a history of mental health difficulties. His condition had deteriorated towards the end of 2013. He was receiving treatment at the Priory Hospital and had a diagnosis of severe clinical depression. Following his diagnosis he was treated with medication and therapy.
On the 8th February the deceased had superficially cut his wrists. This had not required any medical intervention.
On the 11th February 2014 he was attending the therapy group and at the lunch time had an appointment with his Consultant.
During the course of the morning it had been noted by his therapist that the deceased was presenting differently. He was withdrawn and not participating. He was then seen by his Consultant who concluded that the deceased required hospital admission. There were no beds available due to an incident on the ward. A decision was taken that the deceased could return home to his parents' house and would be admitted the following day. On his return to the afternoon therapy session there was increased concern by the therapist who escalated his concerns about the deceased. There was then a further discussion with his consultant but the plan remained the same.
The deceased returned home to his parents' house where he appeared settled. In the early hours of the 12th February 2014 he was found by his parents to have smashed a glass and inflicted a number of serious wounds to himself particularly to his throat and thigh.
Coroner’s concerns
- The quality of the records kept in relation to the deceased was poor and in some circumstances non-existent. No records were kept of the Multi-Disciplinary Team Meetings.
- The Consultant notes were brief and are not kept on the Care Notes system. Such a diverse practice means that there is no overall record of a patient so that all those who have involvement with a patient do not have all relevant, pertinent information available to them.
- No documented risk assessment was completed in relation to the risk the deceased posed to himself.
- No further assessment of the deceased was undertaken by the Consultant after concerns had been escalated following his departure from the group therapy.
- The consultant's out-patient appointment with the deceased had been booked to take place in the lunchtime when we was already in a full day therapy session.
- When concerns were raised in relation to the deceased the further discussions took place in the reception area, an inappropriate environment in which to speak to a patient and obtain important information.
- Given there was no formal risk assessment there was no consideration as to whether the risk management plan was appropriate.
- There was no procedure or policy in place for staff as to what they should do if a patient requires admission but a bed is not available.
Information checked against the published report and official responses