Ryan John EVANS · Prevention of Future Deaths report

On 4th April 2018 I commenced an investigation into the death of Ryan John EVANS. The investigation concluded at the end of the inquest on 23rd January 2023. The inquest was heard with a Jury.

Mr. EVANS died of:
1a: Asphyxia
1b: Suspension by the neck

The jury returned the following narrative conclusion:

Narrative conclusion
Ryan John Glyn EVANS was a 20 year old man with a global learning delay (a learning disability) and was registered disabled. He had a diagnosis of depression which dates back to 2016. He was physically fit and was living on his own in assisted living with seven hours of support a week.

Ryan was adopted at age two along with his older brother and sister and were brought up in a close family unit with his adoptive parents, following a traumatic early childhood.

Ryan was vulnerable due to his learning disability and depression, recent self-harm and attempts of suicide.

Ryan's mental health had deteriorated over approximately seven months due to a number of contributory factors.
- Notice to leave his accommodation and uncertainty of future living plans.
- Finding out the nature of his biological fathers suicide (hanging) via social media
- Medication, drugs and alcohol
- Breakdown in relationship with ACASA management

Ryan was arrested on 2nd April outside ACASA offices for:
-Outstanding criminal damage
-Threatening behaviour
-Violent / Abusive phone calls

Ryan was taken to Frimley Park Hospital by ambulance following collapse in the police van with chest and abdomen pain, his self-harm injuries were dressed and no physical issues were discovered so he was released into police custody. Despite evidence of self-harm, no Mental Health Assessment was carried out at this point.

On booking into police custody, Ryan was noticeably upset. He was referred to and visited by a Health Care Professional (HCP) and Hampshire Liaison and Diversion Service (HLDS) at the request of the police custody sergeant.

-HCP reviewed his physical condition and redressed his self-harm injury
-HLDS failed to document the encounter on the RIO system and only updated the custody record with a screening document.

This follows a failure to update the RIO system in January 2018 when Ryan was previously seen by HLDS.

There was failure to carry out a Mental Health Assessment and no record of Ryan refusing to be assessed. It could not be concluded that these shortcomings significantly shortened Ryan John Glyn EVANS life.

HLDS report screen was completed and uploaded onto the custody record with no reference to a Mental Health Assessment being required or declined by Ryan.

Throughout Ryan's stay in custody he expressed suicidal ideations on multiple occasions, spoke to the Samaritans and concerns were raised by family which were reported back to the custody Sergeant. Communication of this information was ineffective. Additionally, across the custody suite there was a sense of complacency with references to Ryan's behaviour being "attention seeking" and no future referrals to HLDS were made. Despite no formal guidance, it is regrettable that on disposal, no verbal handover was done with Ryan's father. It could not be concluded that these shortcomings significantly shortened Ryan John Glyn EVANS life.

Ryan was released into the care of his father at approximately 22:30 from Basingstoke Custody Centre. He was in a distressed state over the conditions of his discharge and how he found out about his biological father committing suicide by hanging.

Ryan refused to go home to his parents residence and wanted to go to his own accommodation. His father dropped him off around midnight and waited till Ryan was safely in the building.

Ryan was found hanging the following morning, 3rd April 2018, by a fellow resident in the communal area of the building.

Ryan had a long standing history of depression and several suicide attempts.

Ryan John Glyn EVANS took his own life while suffering from the diagnosed medical illness of depression.

The circumstances of the death are recorded in the Jury’s Narrative Conclusion.

Evidence received from the police officers accompanying Mr. EVANS during his attendance at Frimley Park Hospital provided that:

a. Mr. EVANS presented with a large fresh cut on his arm and also cuts on his legs which were identified by him as being from self-harm with hospital staff noting that the larger mark on the arm might require stitching.
b. Police officers stated that Mr. EVANS was open with hospital staff about his feelings of self-harm depression, and thoughts of ending his own life. Officers further recalled that hospital staff noticed and commented on the self-harm marks on Mr. EVANS’ arms, including whilst staff were dressing a recent self-harm wound on Mr. EVANS’ left arm.
c. Officers also recalled Mr. EVANS commenting when offered food by hospital staff that he would rather starve to death.
d. One of the accompanying police officers expressed surprise at the fact that Mr. EVANS was not subject to a mental health referral or assessment, in the context of him commenting to multiple hospital staff members about his self-harm actions and ideation.

An emergency department consultant at Frimley Park gave evidence which suggested that no mental health assessment was or would have been necessary where Ryan’s presenting complaint was recorded as chest pains rather than of self-harm and/or suicidal ideation. Although self-harm had been noted in the records, no explanation could be provided for why Ryan’s suicidal ideation had not been recorded.

The consultant was further questioned in relation to the 2006 NICE Guidelines “Self-Harm: the short term physical and psychological management and secondary prevention of self-harm in primary and secondary care” which are national guidelines that ought to feed into practice at the hospital.

These guidelines provide that “Following triage patients who have self-harmed should receive the requisite treatment for their physical condition, undergo risk and full psychosocial needs assessment and mental state examination, and referral for further treatment and care as necessary” and “All people who have self harmed should be offered an assessment of needs, which should be comprehensive and include evaluation of the social, psychological and motivational factors specific to the act of self-harm, current suicidal intent and hopelessness, as well as a full mental health and social needs assessment.”

Evidence received during the course of the Inquest was not able to reconcile the contradiction between the NICE guidelines on self-harm and Mr. EVANS having had no mental health assessment despite obvious signs of self-harm and further evidence of disclosure of suicidal ideation.

The jury in their Narrative Conclusion found that ‘Despite evidence of self-harm, no mental health assessment was carried out at this point.’

I remain concerned as to how such a situation would be avoided if a patient presented again in similar manner to Mr. EVANS. The additional evidence on PFD matters provided by Frimley Health NHS Foundation Trust does not refer to or address the NICE guidelines on self-harm or explain what would now be done differently were a patient such as Mr. EVANS were to be seen again.

The Frimley Health NHS Foundation Trust additional evidence refers to matters being in the process of introduction and new referral criteria with Surrey and Borders Partnership NHS Foundation Trust, but this does not explain how this would prevent the future risk of a patient such as Mr. EVANS leaving the hospital without a mental health assessment.