Stephen Peter Jackson · Prevention of Future Deaths report

On 23rd August 2018 I commenced an investigation into the death of Stephen Peter Jackson and an inquest is listed to take place on the 4th December 2018.

Investigations to date have identified that Mr. Jackson sent his mother a text message late evening on 10th August 2018 saying “sorry”. His mother contacted Mr. Jackson’s partner after several attempts to get hold of him were unsuccessful. His partner attended Mr. Jackson’s home on the 11th August 2018 and found him deceased lying face upwards on the bedroom floor having entered via an unsecured bedroom window. Drugs paraphernalia was noted at the scene along with a suicide note. The Deceased had deliberately taken an overdose 3 weeks earlier and been admitted to Good Hope Hospital where he self-discharged once medically fit without waiting to be seen by the RAID team. Following discharge he sought a home treatment team input, he was given an outpatient appointment on the 13th August 2018 but the appointment was put back until the 29th November 2018. Evidence to date indicates that he was very frustrated by this delay and reported to family that he could not cope.

Following a post mortem a provisional cause of death has been given as 1a) Diamorphine overdose but the final cause of death is awaited pending consideration of toxicology results.

1. On the 1st August 2018 Mr. Jackson attended his GP and expressed frustration that following his discharge from hospital on the 23rd July 2018. He had not been contacted by the home treatment team and his GP wrote to the Kingstanding and Erdington Home Treatment Team that same day asking them to expedite his appointment, reporting that Mr. Jackson continued to have low mood and negative thoughts and merited an urgent appointment.
2. Mr. Jackson was not seen by mental health clinicians following the GP request.
3. Mr. Jackson wrote a very detailed suicide note within which he refers to feeling unsupported by professionals who did not send him appointments or answers his calls, the context would support this being a reference to mental health professionals.
4. Although evidence at inquest has yet to be heard there is a concern that this case, along with several other cases being investigated by the Birmingham and Solihull Coroners’ jurisdiction, future deaths may arise due to under-funding of mental health services.
5. The strain on the systems of mental health services provided by both Forward Thinking Birmingham and Birmingham and Solihull Mental Health Trust has become apparent to the Birmingham and Solihull Coroners in recent months. Consequently this report to prevent future death is being made in conjunction with reports to prevent future deaths arising from 6 other investigations into deaths between May and August 2018 that demonstrate a risk that future deaths will occur as a result of under-funding.
6. In addition to this report letters are enclosed from the Medical Directors of both Trusts setting out their concerns.