Keith Gallimore · Prevention of Future Deaths report

Keith Gallimore died on 4 December 2014, aged 30. The medical cause of death was the combined toxic effects of heroin and cocaine. The inquest into his death was heard on 1 May 2015, at which I recorded an open conclusion. It was not possible to establish suicidal intent to the necessary standard of proof, nor was it possible to determine that the death was accidental.

Mr Gallimore had a background history of complications following appendicectomy, along with significant psychological stressors, related to his social situation. This resulted in him attending his General Practitioner, in order to seek help for anxiety and depression. He was referred to the ‘iCope’ service provided by CANDI and consulted with a clinical psychologist in November 2014.

Mr Gallimore discussed plans he had made for committing suicide at this consultation, which prompted referral to the ‘Crisis Team’ within the same Mental Health Trust. A referral note was made in the ‘Rio’ electronic medical records which could be accessed by both iCope and the Crisis Team. This set out a summary of the psychologist's consultation, which was fully documented in iCope’s own electronic record system. This system was not accessible by the Crisis Team but a request could be made to iCope for the full documentation to be copied into the Rio records.

I heard evidence from the clinical lead of iCope that he was unclear as to why their records were not accessible by others within CANDI but considered that there may be issues regarding the potentially sensitive nature of these notes. He also set out his expectation that notes made by iCope should be duplicated in the Rio notes.

A member of the Crisis Team reviewed Mr Gallimore a day after the referral was made, at which time he did not report any ongoing plans for suicide, nor was he thought to have a mental health diagnosis. He was discharged from the Crisis Team at this point (with ongoing plans having already been made for follow-up within CANDI).

Unfortunately, he was found deceased at his home address on 4 December 2014.

(1) I am concerned that potentially important information, documented by a service provided by CANDI, is not accessible by other services within the same Trust, without a proactive request being made. It was not clear why this restriction is in place, nor what steps could be taken if information were required in an ‘out-of-hours’ setting, at which time the iCope service would not be available to copy notes to Rio.

Although there was no evidence that, had the iCope notes been available to the Crisis Team, the outcome of Mr Gallimore's case would have been different, I am concerned that future deaths could result because of this issue.