Jamie Raymond Barlow · Prevention of Future Deaths report

On 28th of August 2012 I commenced an investigation into the death of Jamie Raymond Barlow, aged 29. The investigation concluded at the end of the inquest on the 25th of March 2014. The conclusion of the inquest was that Jamie Barlow took his own life.

Jamie had been a patient of the Suffolk Early Intervention in Psychosis Service and had previously been discharged from the service having appeared to make progress and to have reasonable insight. The General Practitioner then contacted the service again having had an unusual phone call from Jamie in which he had claimed to have drunk bleach 10 days earlier (though whether this had, in fact, happened was questioned medically at the time and was not certain) and was expressing other comments that caused concern. There was not felt to be a need to see him as an emergency that day, but there were clearly communication problems about the plans that were then made for a subsequent assessment of Jamie. Jamie then failed to attend an appointment at the GP’s surgery. The Mental Health Services were concerned about visiting him at his home, as there had been mention of him having weapons there, and police were not willing to conduct a welfare check without mental health personnel accompanying them as, based on the information they were given, they believed it might exacerbate the situation. Sadly, Jamie’s body was found hanging some days later, in the area of his home but not easily visible.

The significant extent of the post mortem changes to the body were such that it could not be established that a visit at the time requested would have avoided the tragic outcome in this particular instance but, although the inquest heard of some changes that had been made since the death, it was clear that there needed to be better inter-agency working, clarity when police assistance was sought in respect of exactly what they were being asked to do, a need to look at the processes operating here, and consideration of an inter-agency protocol for jointly managing the mental health assessment of patients who require such assessments but where there is a perception of risk to mental health professionals or members of the public.