Pin
Get email alerts
Request correction
Investigation and inquest
On 26th November 2019 I commenced an investigation into the death of Steven Paul David Gary Stout aged 40. The investigation concluded at the end of the inquest on 2nd March 2021. The conclusion of the inquest a narrative conclusion:
“Mr Steven Stout was detained by police on the morning of 14 October 2019 under section 136 of the Mental Health Act 1983. Mr Stout was intoxicated by alcohol and had cut both of his wrists.
Following medical treatment for his injuries Mr Stout was assessed at the section 136 suite at hospital. Following a Mental Health Act assessment, Mr Stout was made subject to an order under section 2 of the Mental Health Act 1983. After a three-day delay Mr Stout was admitted to a mental health ward on 17 October 2019.
On the ward Mr Stout is assessed by a consultant, it was determined that he ought to be discharged from the section two order with support in the community from the home treatment team.
Mr Stout was discharged from the ward on 18 October 2019 without a referral to the home treatment team, accordingly he was not supported in the community by them.
On 4 November 2019 Mr Stout was found unresponsive, suspended by his neck from a ligature. Despite the prompt attendance of emergency services, he could not be resuscitated and his life was pronounced extinct at 07:43 hours. Mr Stout had deliberately taken his own life.
Although it is possible that home treatment team support in the community could have avoided this outcome, it cannot be said, on the balance of probability, that home treatment team intervention would have probably provided an opportunity to save or preserve Mr Stout’s life.”
The medical cause of death was: 1a Suspension
Circumstances of the death
See above narrative
The published report provides this section by reference to another part of the report.
Coroner’s concerns
1. The failure of Turner Ward, Goodmayes hospital to accurately record and file important medical records including; decisions on discharge, risk assessments, and a crisis, relapse and contingency plan.
2. The failure of Turner Ward Goodmayes hospital to ensure the effective referral of a patient from the ward to the home treatment team within the community.
