Jan Goodliffe · Prevention of Future Deaths report

Jan Goodliffe died on 15th June 2021 at an address where he worked in Rochford Essex due to ████████. He had a long history of Mental Health problems during his life and had periods as an inpatient during his life. A few days prior to his death, he had tried to ████████ himself, but a family member had found him and prevented anything happening. Mr Goodliffe lived with his wife and was consistently expressing views around him wishing to take his own life. He was visited by clinicians prior to his death, who were not medically qualified, yet deemed him not at risk of suicide, despite his wife expressing concerns and telling them that he had taken medication to calm himself down prior to their arrival and setting out his attempt to take his own life a short while prior. It was also in evidence that Mr Goodliffe had been prescribed medication by his psychiatrist in March of 2021, however, there appears to be an issue with how these to be on repeat prescription, evidence showed that ████████ was potentially meant to reorder these, and a mistake occurred which meant he went without this medication for Bi Polar for the month of May 2021. It was communicated to the clinicians that attended to see Mr Goodliffe of his apparent decline with the medication for the month period (he had at that appointment restarted this medication) However when he had been first prescribed this medication, he was an inpatient and the trust extended his inpatient stay to ensure the medication was working correctly. All this was communicated to the clinicians at the home appointment. Several days later Mr Goodliffe took his own life.

That the Clinicians who attended to assess Mr Goodliffe where not medically qualified, they were social workers. They were presented with evidence around a serious attempt by Mr Goodliffe to take his own life that he had been doing by a family member. ████████ gave all this information at the assessment along with the recent reintroduction of the Bi Polar medication, and the facts of the previous reintroduction when starting this medication and the time taken for this medication to start to work. As they were unqualified medical practitioners, there were missed opportunities to seek qualified medical advice around the interactions of the medication and whether as a result of this contributed to his death.

I am concerned that suitably medically qualified clinicians are not being used in the home assessments and decisions are being made around issues that require medical expertise.