Kyle Ashley Smith · Prevention of Future Deaths report

On 25th October 2013 I commenced an investigation into the death of Kyle Ashley Smith, 27. The investigation concluded at the end of the inquest on 9th January 2014. The conclusion of the inquest was an Open Verdict with the cause of death being 1a) The combined Toxic Effects of Tramadol, Codeine and Zopiclone.

(a) On the morning of the 19th of October 2013 Kyle Smith’s wife tried to rouse him but he did not respond. She summoned an ambulance and when the ambulance crew attended they told her that Mr Smith, who was then aged 27, had died. A subsequent Post Mortem examination including toxicological testing of samples revealed that the medical cause of Mr Smith’s death was that it was due to the combined toxic effects of Tramadol, Codeine and Zopiclone.

(b) Mr Smith had a history of what his GP described as “mood problems” dating back to 2005. On the 15th of October 2013 Mr Smith saw his GP because, again as his GP describes, Mr Smith and his wife were becoming increasingly concerned with regard to Mr Smith’s mood swings and his self harming behaviour. Mr Smith had been harming himself by cutting his arms with razor blades, and his GP gave evidence at the Inquest that she had been shocked by the number and nature of the cuts that Mr Smith had inflicted upon himself.

(c) As a consequence of this Mr Smith’s GP decided to refer him urgently to the Wigan and Leigh Assessment team of the Five Boroughs Partnership NHS Foundation Trust, which is a Mental Health Trust. Accordingly on the 16th of October 2013 Mr Smith’s GP wrote a letter of referral to the team, which she marked “URGENT”. That letter was received by the Assessment Team by fax at 13.04 hours on the 18th of October 2013. Mr Smith’s GP was unable to explain the delay in the urgent referral being sent in her evidence at the Inquest and no investigation into that delay had been made.

(d) On the day that the referral was received a member of the Assessment Team attempted to contact Mr Smith by telephone without success. A further attempt was made the following morning, but by that time Mr Smith had died.

(1) Mr Smith’s GP was concerned about his mental health when she saw him on the 15th of October 2013, to the degree that she decided to refer him urgently to the Mental Health Assessment Team.

(2) That referral did not reach the Team until the 18th of October.

(3) The reason for this delay has not been investigated and is not currently known.