James Alexander David Taylor · Prevention of Future Deaths report

On 12th November 2020 I commenced an investigation into the death of James Alexander David Taylor, 35 years old. The investigation concluded at the end of the inquest on 11th December 2020.
The conclusion of the inquest was a narrative conclusion:

Mr Taylor died as a result of suicide. He took his own life following life changing injuries sustained during a road traffic collision. The injuries sustained in the collision caused a functional neurological disorder manifesting in refractory pain and sensory disturbances. These, in turn, led to psychological distress and suicidal ideation. Mr Taylor sought help for his pain and psychological distress. Long-term psychological therapy was required. The required help was not provided to him. In August 2019, Mr Taylor attended a long awaited multi-disciplinary programme for functional neurological disorder. He had attended preparatory sessions for the in-patient programme, to determine his suitability. The extent of his pain was not explored at the preparatory sessions and his engagement in the programme was terminated after 4 days, due to pain limiting his engagement. It is clear from communication left by Mr Taylor that the feeling of rejection from this programme contributed to his decision to take his own life.

The immediate circumstances of the death can be seen from the narrative conclusion set out above.

In relation to the primary health care provided to Mr Taylor, concerns were raised by his family and friends in relation to the number of different general practitioner surgeries involved in his care and the lack of continuity of care.

Evidence was heard from his final GP, who confirmed that Mr Taylor had a very large volume of medical records due to his complex physical and mental health needs. The practice received an electronic transfer of records. There was no transfer letter or clear summary of his ongoing clinical needs.

As a result of his complex health needs, Mr Taylor changed address on a number of occasions. This required a number of changes of general practitioner surgeries. In 4 years, Mr Taylor had changed surgeries 4 times. The Inquest heard evidence from his final general practitioner who confirmed that there was a large volume of records relating to Mr Taylor. The GP confirmed that no summary of care is provided to GP practices when transfer of patients take place. He confirmed the dangers of this, in that important clinical matters can be missed where a patient has a large volume of records.

The general practitioner indicated that handover summaries should be provided to GPs when complex patients are transferred from surgery to surgery. Such transfer summaries could include a summary of past medical history and highlight acute, ongoing clinical conditions, together with any safeguards around prescribing of medication. Such summaries could ensure safety in the continuity of care