Mark-Anthony SUMMERSETT · Prevention of Future Deaths report

On 16 February 2024 I commenced an investigation into the death of Mark-Anthony SUMMERSETT aged 58. The investigation concluded at the end of the inquest on 09 January 2025. The conclusion of the inquest was that:

On 5 February 2024 Mark-Anthony Summerset attended the Emergency Department at Worthing Hospital in the company of a Police Officer. Suicidal thoughts were reported and recorded by reception staff but Mr Summerset left around an hour later before being triaged or assessed for treatment. Over thirty six hours later he was sadly found deceased in his car in the Crown Car Park, Arundel on 7 February 2024, with self-inflicted wounds to his neck; Police ruled out any 3rd party involvement.

Mr Summerset was known to local Mental Health Services (ATS), although he had cancelled multiple appointments for a full clinical assessment. He approached Police on 5 February 2024, at the station in Littlehampton trying to hand himself in for fraud. He stated that he felt he should be punished and everyone would be better off if he was dead. He said a decline in his mental health had led to him self-harming a number of times, but he didn't think he could actually end his life and had thrown away a razor blade just before coming to the police.

Officers took him to Worthing General Hospital Emergency Department to receive help. They helped him sign in at 1840 and he told reception that he was experiencing suicidal thoughts. Officers left him in the care of hospital staff. He was seen around an hour later appearing calm. He was not called for triage until 1946 but did not respond. ED staff notified the MHLT who confirmed he was known to their service. They were only told he was experiencing suicidal thoughts and made internal notification to his lead practitioner. Both teams attempted contact by telephone to Mr Summett's mobile, no to avail. MHLT were unaware that he had been brought to hospital by Police, who were not informed he had left the ED. Nor were his former partner or GP informed. Neither Police nor his partner therefore attempted contact.

On 7th February Police and SECAMB were called at 1415 to report that a male had been found deceased in his car in Arundel, subsequently identified as Mr Summerset.

Whilst I heard evidence that the UHS Foundation Trust has a Missing Person policy – Walkouts/absconding patients (approved 23 May 2024), in Mr Summerset’s case there was a lack of recorded and/or shared information across all the agencies and teams with whom he had contact, or to whom he was known, such that an accurate and fully reflective risk assessment was not achieved, exacerbated by delays in the triage process in the ED.

Mr Summerset was not notified to Police as a missing person and nor were Police informed he had left the ED, despite them simultaneously raising a safeguarding risk via a Vulnerable Adult Single Combined Assessment of Risk Form.

In sum, there was therefore a lack of information sufficiency, flow and sharing across the agencies whilst he was present in, and at and after the point he left, the ED, which might have enabled greater efforts to locate, contact and more urgently treat him.