Peter Frosdick · Prevention of Future Deaths report

On 7 June 2019 I commenced an investigation into the death of Peter Frosdick aged 48 years. The investigation concluded at the end of the inquest on 28 November 2019.The conclusion of the inquest was cause of death 1a) Hanging and that whilst Mr Frosdick took his own life, he was unable to form the necessary intent due to his state of mind.

Mr Frosdick chronically abused alcohol. In 2018 he had blood tests and then a CT scan which showed cirrhosis of the liver. He was advised that he should stop drinking alcohol. He became convinced that he was going to die of liver failure. This was not the case. He had been told this 6 months earlier he would have been able to stop drinking and be saved. This was an irrational view as he was not in liver failure. He was referred to the Mental Health Team/Crisis Resolution/Wellbeing, none of which accepted him for treatment as it was felt that his major problem was alcohol misuse. He was displaying paranoid thinking, was showing extreme anxiety and irrational behaviour. He hung himself in his garage.

(1) That no-one appeared to have looked at his mental health except to note that he was alcohol dependant. This was an escalating presentation from someone who had no previous contact with the services.

(2) His mental state was not classed as a psychiatric illness and since he did not fit neatly under a label he was not taken on. When seen by the Crisis Home Resolution Treatment Team, home treatment was not offered or explored. His mother states that hospital admission was not offered and a referral to Wellbeing Services should have been made but wasn't.

(3) The various teams within the Trust seem to be unaware of each other's referral criteria and displayed little or no professional curiosity and appeared to dismiss his GP's opinion which gave a clear description of his worsening presentation and the fact that he had been abstinent from alcohol.