Investigation and inquest
On the 27th February 2018 I commenced an investigation into the death of Robert Glyn Hughes. The investigation concluded at the end of the inquest on the 29th January 2018. The conclusion of the inquest was suicide. The medical cause of death was 1A Hanging.
Circumstances of the death
Robert Glyn Hughes was a 67 year old man who lived alone. He had a long history of low mood, alcohol and diazepam dependence, and he had taken numerous overdoses in the past. He had been diagnosed with prostrate cancer and was struggling with the diagnosis and the side effects from the treatment. On the 26th January 2018 he took an overdose and was admitted to hospital. After treatment and assessment by the mental health liaison team he was discharged on the 30th January. On the 14th February 2018 Mr Hughes contacted the Crisis team expressing suicidal ideation. After a telephone assessment he agreed to contact his community mental health nurse, and his GP. On the 20th February 2018 the police were contacted by a concerned friend of Mr Hughes. Police attended at his property and forced entry. They found Mr Hughes hanging with a cord around his neck attached to the door in his bedroom. He was pronounced deceased at scene. Mr Hughes had left a suicide note in his living room. Police are satisfied there are no suspicious circumstances surrounding his death.
Coroner’s concerns
(1) The triangle of care approach, where mental health team practitioners seek permission from the patient to approach the patient’s family, is not consistently applied.