William Abel · Prevention of Future Deaths report

On 10 February 2015 I commenced an investigation into the death of William Abel

At inquest held on the 18th September 2015 death by suicide was recorded.

Cause of death
1a severe head injury

Mr Abel was diagnosed with paranoid schizophrenia and was receiving treatment for this severe mental illness. Concerns were raised by the family and general practitioner at the end of December 2014 his condition appeared to be relapsing and a request was made for an expedited appointment, that he failed to attend.

On 8th February 2015 he was reported to be on the railway lines by a member of the public and British Transport and local police attended the scene, removed Mr Abel to a place of safety and arranged a mental health triage team to attend at the local police station to interview him. After the interview it was concluded he was allowed to go home, without criminal charge or any mental health treatment for assessment, with his father.

The following day Mr Abel was seen by members of the public to go onto the railway line at level crossing, despite auditory and visual warnings that a train was coming, and to step in front of a train, where he died instantly.

1. Mr Abel had a diagnosis of paranoid schizophrenia and he was still under the care of the Mental Health services at the time he was found in the vicinity of the railway lines, expressing suicidal intention. He had missed appointments and there was a history of non-compliance with medication. Staff were available to have conducted a Mental Health Assessment, on the night he was safely escorted from the railway lines, but this was not done.

2. Mr Abel was discharged into the care of his father, and inadequate communications were made with the family, as the father was not made aware of the professional concerns regarding a relapse in his mental health, that hospitalisation had been considered and the family was expected to be responsible for his safe keeping. No attempt was made to obtain any family information that could have impacted on the decision to take no further action that night.

3. NICE guidelines (Clinical guidance 136) state that health care professionals should discuss whether the patient would like the family to be involved in their care, and to provide them with information to understand the mental health problem and its treatments. This guideline does not appear to have been met in this case.