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Investigation and inquest
On 10th September 2021 I commenced and concluded an inquest into the death of Anthony James Preston
Circumstances of the death
Anthony James Preston died on the 16th November 2020 at his home address of ████████, Waltham Abbey as a result of suspension by Ligature. He was known to Mental Services and a Serious Incident Report was undertaken by EPUT.
On the evening of the 15th November 2020, the police attended Mr Preston’s home following a concern raised by a friend. Mr Preston let them in but was naked, with lacerations to his wrists and was under the influence of alcohol. He had laid out clothes for his casket and written four notes to his family. He told the police he had attempted to hang himself, but it had gone wrong. An Ambulance was called and Mr Preston agreed to attend A&E. As Mr Preston agreed to go to A & E and was in a private place so the was not detained under the Mental Health Act and they did not escort him to hospital. They were however aware of the severity of his condition at that time. On arrival, basic medical checks were completed and a referral for a mental health assessment was made. However, before the assessment took place Mr Preston was noticed to be missing from his cubicle. When he could not be found the police were informed.
The Mental Health Liaison Team notified his community team of his attendance at A&E and the circumstances of his disappearance. This was followed up straight away the following day and after failure to contact Mr Preston by telephone his support worker and the stand in Care Coordinator called at his home address at 10:30am. After they received no response the police were called and Mr Preston was subsequently found deceased within the property suspended by a ligature.
Coroner’s concerns
That the Police Missing Person Policy should be looked at to see if it is fit for purpose.
Information checked against the published report and official responses