Jeffrey Gash · Prevention of Future Deaths report

On 3rd October 2014 I commenced an investigation into the death of Jeffrey Gash aged 46 yrs. The investigation concluded at the end of the inquest on 5th August 2014. The conclusion of the inquest was “intentionally took his own life”

1. The deceased, following a referral from his GP, met with the Crisis Team on 29th August 2013. He was subsequently seen by his GP again and a Consultant Psychiatrist.
2. On 27th September 2014 the GP received a telephone call from the deceased’s wife saying that she was distressed and was seeing voices. The GP contacted the Crisis Team, spoke to a nurse who gave advice which resulted in the GP making a home visit to assess the situation before further contact was made with the Crisis Team.
3. The Crisis Team nurse, after speaking with colleagues decided not to make a home visit because of personal safety risks and spoke with the deceased on the telephone to discuss his problems, invite him to attend West Park Hospital and when he declined, gave further contact information to assist.
4. On 28th September, the same Crisis Team nurse received a further telephone call from the deceased stating that he was feeling worse, had spoken to the Samaritans but in evidence, the nurse believed this was a positive not a negative position, as he was seeking assistance, sharing his concerns and she decided not to consider taking matters further not requesting a face to face visit or escalating the matter further.
5. The deceased hung himself on 30th September 2013.
6. The deceased left a note and in this he said “ You know I went to see the doctors at West Park Hospital I was hurting every day but they weren’t interested”.

1. The Crisis Team nurse accepted in evidence that she had not been as forceful as she could and should have been to explore with the deceased his new symptoms, auditory hallucinations, hearing voices. This evidences a lack of training and understanding of the nature of and importance of an appropriate level of telephone assessment
2. No evidence was provided at the inquest to indicate a formal Trust policy on when to decline home visits on the grounds of personal safety and security and the nurse relied upon being told of concerns about visiting this property from colleagues but did not record the same or any explanation for her decision. The absence of a clear policy and a policy for recording decisions made or understanding and training thereon is an area of concern
3. Notwithstanding the fact that the deceased declined to attend the hospital for a face to face interview, insufficient weight was given to the reason therefore and whether domestic and other pressures were militating against him attending were not properly considered, if at all.
4. Given that there was an insufficiency of enquiry into the deceased’s state of mind and in particular, a failure to further explore the issue of him claiming to hear voices, on inadequate assessment of risk was undertaken and it was accepted by the Trust in evidence that there ought to have been a face to face consultation with the deceased and that had not agreed to it voluntarily, then there ought to have been a compulsory assessment.
5. The clinical risk assessment and management policy document (Version 5) which was presented in evidence fails to clarify the nature and detail of what form of risk assessment needs to be completed when a one in-person face to face is being undertaken. Thus, the notes entered on the PARIS system were unclear as to their author’s view of risk of self harm where it was accepted in evidence that full details of the assessment of risk and its conclusion are central to the Crisis Team process. The Trust has carried out an SUI. Certain recommendations have been made and are being implemented. The inquest however, as evidenced above, revealed other issues not dealt with by the SUI and therefore a complete re-evaluation of the deceased’s contact with the Trust should be undertaken taking into account the evidence given at the inquest so that a complete overview of Trust policy dealing with the above matters and any other such review might uncover can be considered by management and if agreed, implemented.