A coroner has told an NHS trust to take action to prevent future deaths after a patient took his own life.
Nigel Meadows, senior coroner for Manchester, has written a report following an inquest into the death of Antony Declan Schofield, 52, from Blackley.
He said evidence at the hearing identified eight ‘matters of concern’ relating to Mr Schofield’s death – and that Greater Manchester Mental Health NHS Foundation Trust should act.
Mr Meadows wrote: “In my opinion, there is a risk that future deaths will occur unless action is taken.”
Mr Meadows told the trust in his report:
“In my opinion, action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action.”
The trust has a duty to respond within 56 days of the report being issued. It must contain details of action taken or proposed to be taken, setting out the timetable for action, Mr Meadows said.”
The inquest was told Mr Schofield suffered from a recurrent depressive order and had been taking anti-depressant medication for many years.
He had been trying to reduce his dosage, but was experiencing discontinuation syndrome and had a mental health crisis on August 6, 2019.
Mr Schofield was admitted to Safire Ward at at North Manchester General Hospital on August 8, having been to A&E two days expressing suicidal thoughts.
There was also a family history of suicide, the court heard.
While at Park House, Mr Schofield expressed suicidal thoughts on several occasions, but ‘disclosed no current plan or intent’.
The inquest was told that before he was discharged a comprehensive suicide and self-harm risk assessment was not completed by a member of inpatient staff who had ‘full knowledge of his condition and future care plan’.
On August 22, Mr Schofield attended A&E and reported that he had attempted to end his life the night before.
He said he bought drugs with the intention of killing himself.
Mr Schofield subsequently had several contacts with the HBTT, the last of which was on August 26.
When asked about the drugs, he said he had received them, but thrown them away.
He was found dead on August 27 at home having taken an overdose.
Mr Meadows raised concerns, including:
- That there was no thorough comprehensive risk review undertaken by a member of staff who had detailed knowledge of the deceased prior to Mr Schofield being discharge from the inpatient unit. This was not identified before he left the ward and it was not discovered by the HBTT when they took over his care.
- That the transfer and communication process from inpatient care to the HBTT appeared inadequate.
- That there was no clear plan to deal with the risk of Mr Schofield’s condition deteriorating and him experiencing significantly more suicidal thoughts as well as obtaining the means by which to kill himself. Mr Meadows says in his report: “It is well known that a history of suicidal thoughts and actions increases the risk when they are repeated.”
- That when Mr Schofield said that he bought drugs, there was no risk review planning involving a senior HBTT clinician, which was then monitored even when he indicated he had received them.
- That on several occasions before he died, Mr Schofield saw members of the HBTT, but they failed to demonstrate professional curiosity and enquire about his suicidal thoughts and plans.
- That there were a number of missed opportunities for the HBTT to assess changes in his presentation and risk profile.
- That there was no robust audit system for checking compliance with the trust’s own policies and protocols, in particular with regard to medical record keeping, risk assessments and reviews.
- That the trust’s own investigation report contained several factual errors and misinterpretations and it was only discovered at the inquest hearing that one of the last members of HBBT staff to see the deceased had given an account that was not the same as given to their line manager. There was inadequate overview of the report before it was signed off, Mr Meadows said.
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Source: Manchester Evening News, 14th October 2021
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