Daniel Hubert Collins · Prevention of Future Deaths report

On 03/05/2018 I commenced an investigation into the death of Daniel Hubert Collins. The investigation concluded at the end of an inquest on 31/08/18. The conclusion of the inquest was Suicide.

The Deceased had no known mental health issues prior to attempting to take his own life via an overdose on 07/04/18 when he was admitted to Hospital. He reported being concerned about the poor health of relatives, that his relationship with his girlfriend had ended and the pressure of completing his degree. He was assessed by RAIU nurses on 8 and 9/04/18 and discharged from Hospital on 9/04/18, and because of his young age, was referred to the Forward Thinking Birmingham (FTB) crisis team. An FTB crisis team nurse attended his home on 10/04/18, assessed him, and discharged him from the FTB crisis team to mental health service counselling, putting responsibility on the Deceased to make contact with them. There was no follow up from the FTB crisis team generally, or to check that he had contacted the counselling service. On 25/04/18 he attended a meeting requested by his university to discuss concerns about his wellbeing and mental health. On 26/04/18 he went missing and he was found deceased on 28/04/18 in an area of woodland in Moseley Bog having taken a deliberate overdose.

Following a post mortem the medical cause of death was determined to be:
VENLAFAXINE OVERDOSE

One mental health service, FTB crisis team, transferred necessary mental health care to a second service Living Well consortium (LWC), putting the responsibility of making contact on the patient (aged 22, and only 72 hours post-attempting to take his own life). The rational was “it is part of their recovery, empowers them and gives them choices”. FTB crisis team did not alert LWC to the transfer and did not follow up with LWC or the patient that contact had been made. There was/is no system in place to require FTB crisis team to notify LWC about the transfer or trigger a follow up with LWC/the patient. Therefore, patients are at risk of being lost to the mental health service whilst in crisis/only recently out of crisis.