Keiran Michael John Toman · Prevention of Future Deaths report

On Wednesday 5th September 2012 I commenced an investigation into the death Mr Keiran Michael John Toman aged 39 years. The investigation concluded at the end of the inquest on Wednesday 16th April 2014. The conclusion of the inquest was:

Medical Cause of Death

1 (a) Emaciation

It was clear from the evidence taken during the inquest that Mr Toman suffered with fixed delusions into which he had no insight. He resigned form his job and cut all social contacts. As part of his illness he then cut off contact with his family following his first psychiatric admission under Section 3 of the Mental Health Act in 2007 to Heatherwood Hospital, due to this lack of insight. Despite his lack of capacity to make such decisions, the psychiatric services subsequently involved in his care at Heatherwood Hospital, Wokingham CMHT and the Hafod Community Mental Health Team, North Wales, made no contact with his family, even when as part of his illness Mr Toman removed himself from psychiatric care and follow up. Mr Toman was thus left completely without support and deteriorated until the point where he starved himself to death due to his paranoia and was found deceased in Hyde Park Towers Hotel by cleaning staff.

It was the clear view of the senior psychiatrist from whom evidence was taken in this inquest, that information should be shared with all those involved in the care of such patients including their families/next of kin.

(1) That some psychiatric staff and services may effectively collude with patients by acquiescing to requests not to pass on information to their families, when these decisions are taken by patients who have insufficient insight to make them.

(2) That the lack of contact with families in such circumstances may leave vulnerable patients isolated and increase their risk of deterioration and death, as occurred in this case and in others that I have investigated.

(3) That some psychiatric staff may be insufficiently trained to assess the capacity of patients to decline contact with next of kin and thus the best interest of such patients is compromised.

(4) That where decisions are taken by psychiatric staff not to contact family in line with a patients wishes in order to try and keep that patient engaged with services, that contact is still not made to the family or next of kin even when such a patient disengages from the psychiatric services.

(5) That permission to contact next of kin/ family decisions taken by patients may not be reviewed often enough by those providing psychiatric care, such that information in relation to changes in treatment, mental state, discharge, provider of care etc may not be being appropriately communicated to the detriment of patients.