Source · Prevention of Future Deaths

Steven Cooke

Ref: 2020-0302 Date: 30 Dec 2020 Coroner: Emma Serrano Area: Stoke-on-Trent and North Staffordshire Coroner’s Court Responses identified: 0 / 1 View PDF

There is no national guidance for mental health professionals to engage with patients' families, hindering the collection of a full medical picture.

Date 30 Dec 2020
56-day deadline 25 Feb 2021
Responses identified 0 of 1
Community health care and emergency services related deaths Mental Health related deaths Suicide (from 2015)

Coroner's concerns

AI summary
There is no national guidance for mental health professionals to engage with patients' families, hindering the collection of a full medical picture.
View full coroner's concerns
(1) That there is no national guidance regarding engagement with the family of a Mental Health patient to gain as full a picture as possible.

Report sections

Investigation and inquest
On 18 July 2019 I commenced an investigation into the death of Steven Clive Cooke, aged 56. The investigation concluded at the end of the inquest on 16th December 2020. The conclusion of the inquest was Steven Cooke was found, having passed away, on the 9 July 2019 at his home address of 1a Springfield Grove, Stoke-on-Trent, ST8 7BA. He hung himself by a ligature fashioned from a grey wiring cable fastened to the rafters in the loft. The cause of death recorded at inquest was: 1a) Hanging by ligature.
Circumstances of the death
Steven Cooke first presented to the Mental Health Services within Stoke-on-Trent on the 1 February 2019, after the breakdown of his marriage of 36 years. He was treated as an inpatient and within the community for this, until he passed away on the 9 July 2019. During the inquest it was accepted by the Trust that work was needed nationally regarding gaining input from a patient’s family. Whilst it was accepted that patient’s wishes for information not to be passed on had to be respected, this did not stop the Mental Health Services engaging with families to find out further information regarding a patient. Whilst Stoke-on-Trent Mental Health Services are mandated to engage with families of a patient to ascertain as much information as possible, this does not happen nationally. There is little in the way of national guidance and it will often depend on which area you live in, as to whether this takes place. .
Copies sent to
1. North Staffordshire Combined Healthcare NHS Trust

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Report details

Reference
2020-0302
Date of report
30 December 2020
Coroner
Emma Serrano
Coroner area
Stoke-on-Trent and North Staffordshire Coroner’s Court

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: 25 Feb 2021.

Sent to

NHS England

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