Richard Jeffrey Jones · Prevention of Future Deaths report

On 29/10/2012 I commenced an investigation into the death of Richard Jeffrey Jones aged 23. The investigation concluded at the end of the inquest on 27 January 2015, having heard evidence on 11 July 2013, 13, 14 and 15 January 2015. The conclusion of the inquest was a Narrative one.

Richard was at home on his own and during the period 14 to 15 October 2012 voluntarily ingested such a quantity of tramadol that on a balance of probabilities it lead to a loss of consciousness and respiratory depression leading to aspiration of the gastric contents which caused his death. The reason as to why Richard had taken the medication and his intentions in doing so were unclear.

The witnesses included those employed by Avon & Wiltshire NHS Mental Health Partnership, the Defence Mental Health Service and Salisbury Hospital NHS Trust with whom Richard had come into contact when seeking help for his mental health issues particularly during the period 12-13 October 2012.

It was acknowledged by the witnesses from the Salisbury Hospital NHS Trust that Richard needed to be assessed by an experienced mental health practitioner with a degree of urgency. An assessment had been due to be carried out shortly after 10 am on the 13 October 2012, but Richard left before it could take place.
Avon & Wiltshire Mental Health NHS Partnership Trust in evidence accepted that they took over responsibility for Richard's care following a call from the Hospital to advise that Richard had left. There was contradictory evidence as to whether the appointment had been cancelled or changed to a requirement for a home visit and as to the degree of urgency.

A referral was made by Avon & Wiltshire NHS Mental Health Partnership to the Defence Community Mental Health Service who were only said to provide an advisory service out of hours and not to be responsible for direct contact with patients.

Richard was telephoned at home by a member of the Defence Community Mental Health Service a mental health nurse with 20 years experience

There was contradictory evidence as to what was said during the telephone conversation between AWP and the Defence Community Health Service as to whether it was only an advisory service with no ability to carry out assessments, the degree of urgency and the level of risk.

The reason for writing to each of you is that I understand you have some degree of control with regard to the provision of care for members of the armed forces who appear to be suffering from mental health issues.

I am concerned in particular as to the following matters :

a) As to the way in which information obtained from such a patient is recorded , with especial reference to the perceived level of risk and the degree of urgency in carrying out an assessment.

b) As to how that information is shared with other agencies involved in the care of that patient to ensure that it is accurately passed on, particularly as to the level of risk and degree of urgency.

c) As to who has primary responsibility for the care of that patient and how that is recorded by all those involved, particularly where there is a transfer of care.

I would ask you to review the policy and procedures that you have in place to deal with the referral to another agency of a member of the armed forces who appears to be suffering from mental health issues having regard to the above concerns.