Mr Benjamin Sulzbacher · Prevention of Future Deaths report

On the 9th October 2023, I commenced an investigation into the death of Mr Benjamin Sulzbacher who died on the 27th September 2023. The investigation concluded on the 2nd May 2024. The medical cause of death was confirmed as 1a) Hanging. A conclusion of suicide was recorded.

Mr Sulzbacher had suffered from a deterioration in his mental health for a number of years. This became more acute during 2023. Throughout this time he had accessed assistance from professionals within his community and this was done on a private basis.

On the 24th August 2023 having tried to tie a ligature at home, he was taken to the Accident and Emergency Department at North Manchester General Hospital. He was assessed and it was recognised he required an inpatient admission which he agreed to as a voluntary patient.

Due to the only available acute inpatient bed being in the South, his family funded a private admission at the Priory hospital in Altrincham. He was an inpatient from the 26th August until the 18th September 2023.

On his discharge from the Priory part of the discharge plan was for a follow up phone call within 48 hours. This occurred on the 21st September 2023. Learning from how this call was conducted has already been recognised by the Priory.

The court heard evidence that no referral was made to the NHS mental Health trust for follow up via the Home Based Treatment Team. In this case due to where Mr Sulzbacher lived, a referral would have been to Pennine Care NHS Trust Foundation Trust. This would have occurred automatically if he had been an NHS inpatient.

The court heard if a referral had been made to the Home Based Treatment Team they would have conducted a face to face follow up within 72 hours and if necessary, would have remained engaged with Mr Sulzbacher for up to 4 weeks. The court also heard evidence that the NHS Trust would have accepted such a referral even though Mr Sulzbacher had been a private paying inpatient.

The evidence from the family was that Mr Sulzbacher’s mental health declined on his return home and he died having tied a ligature on the 27th September 2023.

For the Priory

1. There was a lack of understanding from the Priory witnesses as to what the NHS community services could offer on discharge. The court heard that the Home Based Treatment Team was understood to simply be a “Crisis team” which was incorrect.

For All:

1. It was unclear to all services as to whether a private paying inpatient (who would have qualified for care under the NHS but due to bed availability went private) would be entitled to be referred to the discharge services offered by the NHS. The NHS provides more than the private sector in respect of community discharge packages and can be engaged with someone for longer. Importantly the face to face contact enables a better understanding of how a patient is actually presenting when considering their mental health.