Samuel Joseph Gomm · Prevention of Future Deaths report

On 10th June 2019, I commenced an investigation into the death of Samuel Joseph GOMM. The investigation concluded at the end of the inquest on 18th May 2022. The conclusion of the inquest was Suicide.

The medical cause of death was: -

1a. Laceration to neck

These were recorded as: -

Samuel Joseph Gomm suffered from chronic mental ill health exacerbated by periods of alcohol abuse. On 3.6.19 whilst at home at ████████, he has deliberately self-inflicted a number of lacerations to his neck. These have led to acute blood loss and his death. It is more likely than not, that he intended the consequences of his actions to be his own death.

The Inquest focused upon: -

a. The direct circumstances leading to his death.

b. The role that Mental Health & Local Authority Services took in the management of his risk of self-harm in the months preceding his death & whether such management may have contributed to his death.

I recorded no findings in relation to such management, which were directly causative of his death.

At the conclusion of the Inquest, I directed written submissions from the three Interested Person’s as to whether my duty under Regulation 28 was engaged & if so, in respect of which matters.

I have received & considered the same.

(1) The assessment of Sam’s risk of self-harm was recorded by his care-co-ordinator in a Wales Applied Risk Research Network (WARRN) assessment tool in March 2019. This form of assessment was adopted by the Integrated Mental Health Services (Powys County Council & Powys Teaching Health Board) in Powys. I also received evidence that it is used throughout Wales by similar services.

(2) The evidence I received indicated that the WARRN assessment documentation/tool could be routinely accessed, updated & revised by the Integrated Team. It was a fluid document for the purpose of recording information as to the current assessment of risk(s) of self-harm & how that risk(s) was to be mitigated. Whilst I received evidence that in practice, such risk assessments were being undertaken with Sam, the WARRN documentation did not necessarily reflect that, nor was it optimally viewable in terms of clearly recording fluctuating presentations & any accompanying re-assessment of risk.

(3) It appeared to me that the format/layout of the WARRN tool, its accessibility, & in particular, its ability to provide a user with clear & easily viewable information as to how Sam’s risk of self-harm had fluctuated/altered/changed in the months preceding his death, could lead to important information/assessments being lost to a new/infrequent user. This, for example, might be a new care co-ordinator (as in Sam’s case), Crisis Team/Community Nurse, or clinician not previously involved with Sam.

(4) Given the variety of services involved in Sam’s care, this central document, addressing & recording fluctuating risk appeared to me to be a crucial document in the recording of current risk (eg emphasis). The ability of those charged with Sam’s care to view those fluctuations might be hampered by the current presentation of/access to such information. That could lead to an under-estimation of the current risk & sub-optimal mitigating measures being put in place.

(5) The WARRN assessment tool might also benefit from a greater degree of interaction between it & the user. For example, it was clear, on the evidence that Social Worker’s, Mental Health Nurses & Clinicians were all busy addressing the needs (& assessing risk) of a wide number & variety of patients. Prompting (my emphasis) the user to consider & record referrals for, for example, to advocacy services & for capacity assessments might optimise the benefits of the tool & reduce the risk of such opportunities being missed/un-recorded. Such then leading to the potential absence of key information for new/infrequent users when assessing risks of self-harm

It may well be helpful (given the Integrated Services approach to Mental Health Services in Powys) if I were to receive one jointly prepared response from both organisations to whom this Report has been sent.