Martin Thomas BARRETT · Prevention of Future Deaths report

On 9 March 2020 I commenced an investigation into the death of Martin Thomas BARRETT. The investigation concluded at the end of the inquest . The conclusion of the inquest was that Mr Barrett had taken his own life on 25 February 2020 and as such I gave a conclusion of suicide

The medical cause of death after post mortem was

1a Suspension by the Neck

1b

1c

II

Mr Martin Thomas Barrett took part in a telephone consultation assessment with the Priory Group by a Cognitive Behavioural Therapist for anxiety at 8am on the morning of his death. During that assessment, he stated that he had thought about suicide and planned how this may occur but did not indicate any immediate intent. The Therapist informed the Court that she considered that he was high risk of suicide but that he had engaged with her safety planning and had agreed to take steps to keep himself safe. The Therapist therefore made an internal referral for a same day appointment with a Consultant Psychiatrist at the Priory Group for further assessment. This referral was made after the appointment and considered by the Consultant after his morning clinic which was around lunchtime. The Psychiatrist declined the referral as he considered that the needs of Mr Barrett were too complex and would be better resolved within the NHS. This decision was not communicated to Mr Barrett. Sadly he was found hanging at his home address around 3pm that day.

During oral evidence, I was advised that when an onwards internal referral is made to another clinician within the Priory Group which is then declined this is not communicated directly to the patient if the treatment is funded by way of insurance cover. In those cases a notification would be provided to the insurers or the policyholder and then the Priory Group would not have any further contact with the patient. As such, patients that are considered to be higher risk by the clinician at initial assessment may not therefore have the opportunity to imminently consider alternative sources of treatment or receive any advice as to safety netting in the interim as this information is not being provided by clinicians to the patient. From the evidence that I heard it would be reliant on their insurers or corporate policy holders (who may well not be clinicians) to make contact with the patients to inform them of this during which time their health may have further declined or their risk increased.