George Daniel TWIDDY · Prevention of Future Deaths report

On 21 November 2017 I commenced an investigation into the death of George Daniel TWIDDY age 23. The investigation concluded at the end of the inquest on 28 March 2019. The conclusion of the inquest was cause of death: 1a. Hanging. Narrative Conclusion: George Daniel TWIDDY took his own life whilst suffering from severe and distressing psychiatric illness.

At about 14:20 hours on Fifteenth November 2017 George Daniel TWIDDY was found hanging from a tree in Warren Copse, Petersfield. He was taken to Queen Alexandra Hospital, Portsmouth, where he was diagnosed to have suffered an un-treatable brain injury. He died at the hospital at 05:08 hours on Seventeenth November 2017.

At George's Inquest I heard evidence that there was a lack of clarity in the days leading up to his death as to which of the two agencies that had been involved in his care (Hampshire AMHP Service and Southern Health NHS Trust's Early Intervention Psychosis Team) were in a position to provide him with immediate assistance. His parents were confused as to where help would come from and practitioners from the two agencies were unclear as to where the responsibility lay. Although an improved explanatory leaflet for families about the responsibilities of the agencies is now in the course of being finalised and liaison to clarify respective roles has now taken place between senior managers of the agencies, it appears to me that a better understanding of those roles would be achieved if the practitioners actually involved in patient care themselves liaised more about what action and support should be made available to patients and relatives in crisis situations such as that faced by George and his family in the last days of his life.