Andrew Elliot FROST · Prevention of Future Deaths report

On 30 September 2014, I commenced an investigation into the death of Andrew Elliot Frost, aged 34 years. The investigation concluded at the end of the inquest yesterday.

I made a determination that Andrew Frost took his own life.

Mr Frost jumped in front of an underground train early in the morning on 25 September 2014.

The day before his death, he had three separate encounters with the authorities, the first with police; the second with police, paramedics, general practitioner and crisis team; the third with police and paramedics.

On each occasion, concern was shown for Mr Frost and attempts were made to assist him.

During the second encounter on 24 September 2014, whilst police and paramedics were at Mr Frost’s home, Mr Frost and his general practitioner spoke on the telephone.

The general practitioner was worried about Mr Frost and made an immediate referral to the Islington Crisis Team at Highgate Mental Health Centre. He was told that the team did not have sufficient resources to go out to see Mr Frost that afternoon, but that someone would ring him.

1. There was no shared understanding between the crisis team and the GP about what the crisis team could and could not do.

The GP thought that the crisis team’s telephone call would include a conversation sufficiently detailed to allow the crisis team to decide whether to conduct a mental health act assessment that afternoon, whereas the crisis team simply intended to arrange an appointment for the following day.

The GP regarded the crisis team as an emergency service, which the team leader told me in court is not the case.

It seems that this GP, his partners, and the other general practitioners who refer patients to crisis teams, would benefit from a very specific piece of training and education from the crisis team about their service, including its limitations.

2. The crisis team’s records did not reflect some valuable information that was passed to them.

For example, that police and paramedics were with Mr Frost at the time of the GP’s call. This information was communicated by the GP and by Mr Frost’s partner. If the crisis team had considered this information, they could have advised Mr Frost’s partner he should tell the paramedics that the crisis team were not coming out that day, which may have assisted paramedics’ decision making.

3. The pager messaging service used by the crisis team simply takes the name of the patient and a telephone number to call, nothing more.

This means that valuable time was wasted by the crisis team, trying to track down the police officer who had rung to find out more detail, most especially Mr Frost’s address.

This is time that could be used treating patients.

I did not hear evidence that led me to conclude that different action by healthcare professionals on 24 September would have changed the outcome for Mr Frost, but it might for someone else.