Timothy Robert DE BOOS · Prevention of Future Deaths report

On 6th February 2024 I commenced an investigation into the death of

Timothy Robert DE BOOS

The investigation concluded at the end of the inquest on 5th December 2024. The conclusion of the inquest was that the death was the result of:-

The effects of a self-inflicted fire at his home address, whilst suffering a relapse of his known psychotic illness.

The medical cause of death was confirmed as:

1a Smoke inhalation and severe burns
1b Domestic fire
2 Paranoid schizophrenia, severe right coronary artery atherosclerosis

Timothy De Boos was declared deceased at his home address in Ipswich, Suffolk on the 6ᵗʰ February 2024.

Earlier that day a fire had to be seen coming from the ground floor flat of the address.

Tim was seen by a witness to close the window of the flat whilst it was on fire, then disappear from view.

Tim made no attempt to leave, and when found was sat or slumped against the door of the room.

Timothy was known to the mental health services, and had a prolonged history of being mentally unwell (being diagnosed with paranoid schizophrenia in 2004), with evidence of a previous stated suicidal thought.

A subsequent post-mortem examination identified that Tim had died from smoke inhalation and burns.

Although clearly able to do so Tim made no effort to leave the burning building, and on a balance of probabilities basis, deliberately remained inside with a view to ending his life

Tim had suffered a mental health crisis on the 2ⁿᵈ February 2024 and Tim himself, Tim’s family, and Tim’s Mental Health Care Coordinator, all believed he should be admitted to a Mental Health Unit at that time as a voluntary patient. This could not be immediately actioned as a referral to another team was required, and members of that team who subsequently saw Tim the following day, deemed he was no longer in a mental health crisis.

If Tim’s admission to hospital had been actioned on the 2ⁿᵈ February 2024, he could not have been admitted in any event, as there was already a list of five other individuals waiting to be admitted to the same unit.

Had Tim been admitted to a Mental Health Unit on the 2ⁿᵈ February 2024, his tragic death would not have occurred.

1. I am concerned of the continuing lack of Mental Health Unit inpatient beds in Suffolk, and more widely throughout England and Wales.

At the time of Tim’s mental health crisis on the 2ⁿᵈ February 2024, had the decision to admit him been possible, he still would not have been admitted as there were five other individuals in the queue before him also waiting for admission.

The lack of available beds is not a new problem, and I have previously issued two Regulation 28 Prevention of Future Death Reports in which a lack of inpatient Mental Health Unit beds have contributed to a death-

Nicola Rayner (died 10ᵗʰ June 2023), reported 7ᵗʰ March 2024.

Piotr Kierzkowski (died 17ᵗʰ December 2019), reported 12ᵗʰ October 2020.

2. In Tim’s case, on the 2ⁿᵈ of February 2024 Tim’s family, Tim himself, and Tim’s Mental Health Care Coordinator (a Senior Mental Health Nurse who had been supporting Tim for a year), all wished for his admission to a Mental Health Unit as a voluntary patient.

It was heard in evidence that a different team (the Crisis Resolution and Home Treatment Team) were the ‘gatekeepers’ for admission and this team could not review Tim until the next day.

When reviewed by Crisis Resolution and Home Treatment Team staff (who had never met Tim before), they believed his crisis had subsided and his admission was denied.

In evidence Tim’s Mental Health Care Coordinator was adamant that Tim should have been hospitalised on the 2ⁿᵈ February, as both his family and Tim himself had also wished.

I am therefore concerned that the views of an experienced mental health professional, a patient’s family, and the patient themselves, is deemed insufficient evidence for an admission to a Mental Health Unit as a voluntary inpatient.