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Investigation and inquest
On 23 May 2023 I commenced an investigation into the death of CALLAN NORMAN COLLINS ATKINS. The investigation concluded at the end of the inquest on 26 June 2025. The conclusion of the inquest was as set out below.
Circumstances of the death
On 18 May 2023 Callan was found hanging from a rafter at his home address. He was confirmed dead at the scene by a paramedic. The Police confirmed that there was no third-party involvement. He had recently undergone neurosurgery for epilepsy and believed that this had worsened his medical condition.
His family considered that, at the time of his death, he was in a negative mindset and was constantly thinking about ending his life. It was clear that Callan took his own life and intended to do so.
At the time of his death Callan was receiving assistance from clinicians in the NHS Mental Health Intermediate Care Team. There was a telephone appointment held between a member of that team and the deceased on 17 May 2023. Thereafter, an arrangement was made for a clinician from the mental health Crisis team to contact Callan on 18 May 2023 to arrange a face-to-face visit.
A subsequent enquiry concluded that there was an opportunity missed to conduct a face-to-face assessment on 17 May 2023 between Callan and a member of the Crisis team. This would have been the ideal position. This was not possible due to the Crisis team’s high clinical workload on 17 May 2023 albeit the Crisis team could have explored whether clinical agency staff were available to supplement the staff on 17 May 2023.
However, the evidence did not disclose that there was any possible or probable contribution to Callan’s death flowing from the Crisis team not seeing Callan on 17 May 2023.
Coroner’s concerns
That staff capacity of the mental health crisis team of the Gloucestershire Health and Care NHS Foundation Trust will dictate whether a patient is assessed on the same day when their clinical needs demand the.
That the Trust will not make any enquiries as to additional resources when their local Crisis team has no capacity.
Information checked against the published report and official responses