Danny James Holt-Scarpens · Prevention of Future Deaths report

On the 14th October 2019, I commenced an Investigation into the death of Danny James Holt-Scarpens, born on the 5th March 1996. The Investigation concluded at the end of the Inquest on the 18th March 2020.

The medical cause of death was: -

1a) Hanging

The Inquest conclusion was Suicide.

On the 10th October 2019, the deceased was found dead at his home address, having used a rope as a ligature to hang himself. The deceased left goodbye notes expressing his intentions.

The deceased suffered from anxiety and depression and was receiving active treatment for these conditions. On the 30th July 2019, the deceased family sought help from the crisis team following concerns for his welfare. The assessing clinician did not create any contemporaneous records of the telephone consultation which took place but it is accepted that the family was informed that the deceased had capacity to make decisions and did not wish to engage with this service, no interventions could take place. The family were advised to contact the police if they had any welfare concerns.

On the 06 September 2019, the deceased saw his General Practitioner, complaining of low mood. During the assessment, he did not make any mention of any active thoughts to end his own life. The deceased had contact with the police on the 02nd and 07th October 2019, where no concerns were recorded about any suicidal thoughts. This is disputed by the family and from the evidence heard it is not possible to resolve this factual dispute.

During the Inquest, evidence was heard that: -

i. There should be better interagency working and sharing of key information between agencies who had contact with the deceased in the period leading up to his death.

ii. The assessing crisis team clinician who undertook the telephone assessment with the deceased on the 30th July 2019, did not make contemporaneous records or document any decision-making rationale including detailing the capacity assessment undertaken.

1. I request that The Chief Executive of North West Boroughs Healthcare NHS Foundation Trust, reviews its staff training and policies in relation to these matters.