Kieran Joseph Kevan CRIMMINS · Prevention of Future Deaths report

On 29 March 2019 I commenced an investigation into the death of Kieran Joseph Kevan CRIMMINS. The investigation concluded at the end of the inquest . The conclusion of the inquest was Suicide.

1a Hanging

1b

1c

II

I found that Kieran Joseph Kevan Crimmins took his own life and intended to do so in circumstances where ongoing psychiatric monitoring and support would have been appropriate. A decision was taken not to refer to the Community Mental Health Team for ongoing monitoring of his mental health and care co-ordination following his discharge from the Crisis and Home Treatment Team on the 5th March 2019 due to the fact that he was receiving support from the Dyfed Drug and Alcohol Service and the Independent Psychological Therapy Service.

(1) I was told that the Crisis Recovery and Home Treatment Team ("CRHT") use the Care Partner records, a whiteboard and a manual diary to enter the various information and action points and that it is at the Multidisciplinary Team meetings that the actions or steps are discussed and progressed. They are either crossed out, if completed, or moved to the next date until they have been actioned. It was highlighted that in this particular case two actions were not completed either prior to Kieran’s discharge from the CRHT or shortly thereafter. In one of these, the entry had been crossed out, giving the impression that the matter had, in fact been dealt with when it had not. This indicated that there was an issue as to the monitoring and execution of such actions or steps.

This anomaly whereby a significant step may have been overlooked remains a concern.

(2) The evidence I heard from one witness described how she was asked to contact Kieran by telephone and to advise him of the fact that a Multi-agency Referral Form (“MARF”) was to be submitted. I considered this was an inappropriate means of communicating a significant procedure and which could potentially bear on his (or any other vulnerable person's) state of mind.

What was unclear is how the provision of this information and step to be taken will be approached in future.

(3) I expressed concern that someone having been discharged from the CRHT, there appeared to be no route back into the Mental Health Service short of a re-referral to the CRHT itself via A & E for someone who remains vulnerable by reason of their mental state and who is receiving therapy as part of the discharge plan. This is in the context of someone who was receiving support from the Integrated Psychology Service (“IPTS”) and the Dyfed Drug and Alcohol Service (“DDAS”), both of whom were engaged in providing appropriate therapies.

My concern is that there appears to be an issue in relation to lines of communication and information sharing between Primary Mental Health Services and Tier 2 providers of therapy.