John Gerard JONES · Prevention of Future Deaths report

On 16th February 2016 an investigation commenced into the death of John Gerard JONES, Aged 57.

The investigation concluded at the end of the inquest on 1st August 2016. The conclusion of the inquest was that the medical cause of death was

1a Drowning

And the conclusion was Suicide

Mr. Jones had been receiving support because of his perceived risk of suicide from late December 2015. On 2 January 2016 he was assessed and admission to hospital was recommended by approved psychiatrists, but the decision was taken not to admit him. On 13 January 2016 he was discharged from further support and on or around 1 February 2016 he took his own life by drowning himself in the River Avon.

(1) Mr Jones was initially referred to the Crisis Team because his GP believed that Mr Jones’ suicide risk could not be safely managed within the community.
(2) When Mr Jones was in due course discharged from the Crisis Team's care it was approximately a week before his GP was notified of that discharge. That notification was received by fax.
(3) This meant that during the important period immediately after discharge from the Crisis Team's care there was a period of approximately a week when Mr Jones was (notionally) back under the care of his GP, but his GP was unaware that this was the case: this meant that Mr Jones would have had no support within the community during this period aside from a single follow up / post-discharge call from the Crisis team.
(4) In evidence the GP indicated that it would have been helpful to have been contacted by telephone at the time of Mr Jones’ discharge and notified of it.
(5) It did not appear to me that there was any clear provision within the Crisis Team’s training / structure / protocols for the sort of communication envisaged by Mr Jones’ GP.