James Savo · Prevention of Future Deaths report

On 06/12/2013 I commenced an investigation into the death of James Savo, aged 27. The investigation concluded at the end of the inquest on 01 June 2015. The conclusion of the inquest was a Narrative Conclusion Mr Savo's cause of death was 1a Hanging and the Narrative Conclusion is as follows "James Savo had a longstanding history of depression. Following his first period of inpatient treatment he was discharged home on 29 November 2013. At the time of his discharge insufficient weight was attached to both the timing and nature of the home treatment team's input and also to family concerns and issues. On balance this led to earlier discharge that should have been the case. Mr Savo hanged himself in woodland off School Lane on 3rd December 2013. Had Mr Savo not been discharged on 29 November 2013 it is unlikely that he would have died at the time he did."

Mr Savo had a long standing history of depression. In October 2013 he had his first period of inpatient treatment. During that time there was a change in his anti-depressant, assessment on the ward and four periods of home leave, three of which were with his family the fourth period and, longest, was with a friend. There was insufficient communication with the family regarding Mr Savo's presentation and their views on home leave. The last direct Home Treatment Team involvement was some 9 days prior to discharge when there was still issues with Mr Savo's home environment, family tensions. There was a need for on-going assessment of his response to medication. He had continuing suicidal thoughts. There was noted to be improvement in the ward setting although he was not as well whilst at home. After a seven day period of leave with a friend Mr Savo returned to the ward where he was then discharged back to his home environment; a Home Treatment Team representative - was not present at this meeting. Their last involvement would have been documented in the computerised records, with the last assessment being some 9 days prior to discharge. There was no evidence of communication with the family/carers at this time. Following Mr Savo's discharge there was a crisis situation 2 days later where the decision was made to continue James' treatment in the community setting (whilst he remained at home). 4 days after discharge on the 3rd December Mr Savo hanged himself.

(1) The systems described as being in place which should be followed to ensure effective communication between families/carers appear not to be routinely followed. As this communication is an integral part of a patient's management and future treatment plans it is essential that all staff are aware of the communication, the nature of it and who has primary responsibility for ensuring that it takes place. Furthermore, there is no evidence of any effective auditing process to ensure such systems are being followed.
(2) The early discharge plan was described as a mechanism to try and ensure a seamless transition from inpatient care to community based care in appropriate cases. Whilst this is clearly a system adopted locally and currently being re-evaluated, given it's significance in facilitating smooth transitions at a time which was recognised as being difficult for many patients returning to the community, consideration should be given as to whether the current guidance etc adequately incorporates the ethos and workings of the early discharge plan. Witnesses knowledge and understanding of this pathway was variable.