Source · Prevention of Future Deaths

Timothy Steele

Ref: 2021-0076 Date: 15 Mar 2021 Coroner: Veronica Hamilton-Deeley Area: City of Brighton and Hove Responses identified: 0 / 1 View PDF

Inefficient processes led to a patient being lost to follow-up and failure to appoint a Lead Practitioner, exacerbated by fragmented and inconsistent application of the Care Programme Approach (CPA).

Date 15 Mar 2021

56-day deadline 10 May 2021 est.

Responses identified 0 of 1

Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Suicide (from 2015)

Coroner's concerns

AI summary

Inefficient processes led to a patient being lost to follow-up and failure to appoint a Lead Practitioner, exacerbated by fragmented and inconsistent application of the Care Programme Approach (CPA).

View full coroner's concerns

the course of the inquest the evidence revealed matters giving rise to concern: In my opinion there is a risk that future deaths will occur unless action is taken. : (1) Mr. Steele was lost to ATS follow up apparently due to inefficient processes and a failure to appreciate the urgent need to appoint a Lead Practitioner for him. In particular the focus and delivery of the Care Programme Approach (CPA) as set out in national guidance 'Refocusing the CPA-and Positive Practical Guidance" does not appear to have been followed_ (2) In addition Sussex Partnership Foundation Trust appears to take a fragmented approach to its policies. Business is conducted in one in Brighton and in another way, for example, in East or West Sussex and yet patients could be in Sussex depending on availability_ would apparently be dealt with differently depending on their geographic location. At Tim Steele's Inquest it was clear that staff members were not aware 0 how matters would be dealt with in other parts of Sussex

Report sections

Investigation and inquest

On 14th August 2020 | commenced an investigation into the death of Timothy Julian STEELE The investigation concluded at the end of the inquest on 1Oth March 2021. The conclusion of the inquest was HE TOOK HIS OWN LIFE"

Circumstances of the death

Tim Steele was a 28 year old man with, effectively, a lifelong history of low mood and depression with suicidal ideation: He described his first suicide attempts as place before he was 10 years old. He was socially isolated and this was emphasised when he was furloughed from work and spending most of his time alone in his studio flat in Brighton: During 2020he made five or six attempts to kill himself: Prior to that; he had been in the care pf the Children and Adolescents Mental Services, had had an informal admission following suicidality in 2014. Had a further episode of treatment from 2017-2018 and finally came to the attention of Sussex Partnership City taking

VERONICA HAMILTON-DEELEY DL,

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you AND your organisation have the power to take such action:

Copies sent to

2. Secretary of State for Health, Department of Health3. Chief Executive, NHS England4. Chief Executive, CQC5. Dr Brighton and Hove CCG, 6_ Head of Quality & Nursing CCG

Similar PFD reports

Shared signals

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Report details

Reference: 2021-0076
Date of report: 15 March 2021
Coroner: Veronica Hamilton-Deeley
Coroner area: City of Brighton and Hove

Responses identified

Responses identified 0 of 1

1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 10 May 2021 (estimated).

Sent to

Sussex Partnership NHS Foundation Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.