Colin Tyson · Prevention of Future Deaths report

On 13/08/2014 I commenced an investigation into the death of Colin Tyson, 51 . The investigation concluded at the end of the inquest on 10 February 2015. The conclusion of the inquest was Suicide. The cause of death was:

1a. Severe, extensive external and internal injuries and fractures
1b. Railway collision

Mr Tyson was a private man who had been significantly affected by a physical injury that had limited both his ability to enjoy his sports, for which he had a real passion, and had also led to him being off work for quite some time which was significant for a man who had such a strong work ethic. It was clear that he was struggling to deal with these issues and his perception as to how others might now be viewing him. He attempted to end his life on the 6th August 2014 by way of carbon monoxide poisoning from his car but was taken to hospital and resuscitated. A mental health assessment took place in hospital where he denied further suicidal ideation. An assessment by the general practitioner of the 7th August led to him again being assessed as not requiring any acute psychiatric input. Accordingly no referral was made to the psychiatric services at this time. It became clear during the course of the evidence from family members that Mr Tyson continued to harbour thoughts of suicide and had even been planning how he might do this. On the 11th August 2014 Mr Tyson stepped in front of a high speed train, dying instantly as a result of the impact. The family expressed grave concerns regarding their efforts to pass on information to the GP in the community when they tried to express their concerns to the GP. The concern from the GP practice related to patient confidentiality issues. I am quite satisfied that the family members did have pertinent information which would have benefitted the GP in his assessments. There is a need for there to be a way in which concerned family members of vulnerable persons (even if not falling under the usual category of a child or an elderly patient/person) should be able to pass on relevant information to the general practitioner. Whilst I am not convinced this would have altered the outcome in Mr Tyson's case it may well make all the difference in some cases where persons are in a particularly vulnerable state due to life events at that time. The general practitioner ████████ shared those concerns and was taking matters back to his private practice but as I felt this raised wider issues for many GP practices ie where GPs might interpret patient confidentiality to extend to not being able to receive critical information. I wish to draw these matters to your attention.

(1) Concern regarding GPs interpretation of patient confidentiality preventing concerned family members passing pertinent information regarding vulnerable persons who are potentially at risk of suicide.