Source · Prevention of Future Deaths
Arun Viswambaran
Ref: 2019-0487
Date: 24 Jan 2019
Coroner: Sarah Bourke
Area: London Inner (North)
Responses identified: 0 / 1
View PDF
Excessive waiting times of up to 18 weeks for IAPT therapy and difficulties in contacting the team risked mental health deterioration and disengagement from services.
Date
24 Jan 2019
56-day deadline
21 Mar 2019 est.
Responses identified
0 of 1
Coroner's concerns
Excessive waiting times of up to 18 weeks for IAPT therapy and difficulties in contacting the team risked mental health deterioration and disengagement from services.
View full coroner's concerns
1) From the evidence of Mr Viswambaran’s GP, , it transpired that the waiting time for IAPT therapy is in the region of 12 weeks but could be up to 18 weeks. I am concerned that individuals may experience a deterioration in their mental health pending an appointment or disengage from mental health services due to the length of waiting times for therapy.
2) Mr Viswambaran had problems making contact with the IAPT team by telephone in order to arrange the initial triage telephone call. I am concerned that this may discourage people from pursuing assistance from the service.
2) Mr Viswambaran had problems making contact with the IAPT team by telephone in order to arrange the initial triage telephone call. I am concerned that this may discourage people from pursuing assistance from the service.
Report sections
Investigation and inquest
On 21 September 2018, Senior Coroner Mary Hassell commenced an investigation into the death of Arun Viswambaran aged 27 years. The investigation concluded at the end of the inquest on 9 January 2019.
The conclusion of the inquest was that Mr Viswambaran committed suicide.
The medical cause of death was: 1a dihydrocodeine and paracetamol toxicity
My short form conclusion was that “Mr Viswambaran took his own life at his home on 18 September 2018”
The conclusion of the inquest was that Mr Viswambaran committed suicide.
The medical cause of death was: 1a dihydrocodeine and paracetamol toxicity
My short form conclusion was that “Mr Viswambaran took his own life at his home on 18 September 2018”
Circumstances of the death
Mr Viswambaran had recently started living with his partner in Tower Hamlets but remained registered with his family GP at the Redbridge Surgery, 49 Windermere Gardens, Ilford, IG4 5BZ. On 16 July 2017, he saw his GP and reported that he was depressed. His PHQ9 score of 19/27 suggested that he had moderately severe depression. He denied thoughts of suicide or self-harm. Following a discussion, he was prescribed Sertraline 50mg, given the crisis team contact number and details of how to refer himself to the IAPT service. He was reviewed on 3 August 2018 when he reported that he had not noticed much improvement in his mood and that he had tried to contact IAPT but had not had any response. It was decided that he would remain on Sertraline 50mg and would have a further review in 3 weeks’ time. His family and friends noted that he was engaging less with other people, his mood was lower and that he was being increasingly critical of himself. Arun had a triage telephone call with the IAPT service and was placed on the waiting list. He did not attend any further GP appointments and would have run out of Sertraline in early September. On 18 September 2018, Mr Viswambaran told his partner that he was working a night shift and would be spending the day at home. He resigned from his job by email later that morning. In the early afternoon, he sent a number of text messages which concerned his friends. When they were unable to make contact with him, they asked police to break into the property. Mr Viswambaran was found dead in the bath. A subsequent post-mortem examination found that he had overdosed on co-dydramol tablets.
Copies sent to
and Senior Coroner Nadia Persaud (East London Coronial Area)
Similar PFD reports
Related inquiry recommendations
Muckamore Abbey Inquiry
Access to mainstream mental health services
Muckamore Abbey Inquiry
Access to allied health professionals
Muckamore Abbey Inquiry
Psychology input to reduce restrictive practices
Muckamore Abbey Inquiry
Funded access to primary care
Infected Blood Inquiry
Severe Psychological Harm
Infected Blood Inquiry
Supplementary Route for Affected Persons
Infected Blood Inquiry
Support Services for Applicants
Infected Blood Inquiry
Bespoke Psychological Service
Brook House Inquiry
Improve HMIP and IMB evidence gathering and reporting processes
IICSA
Rehabilitation code for CSA civil claims
Report details
- Reference
- 2019-0487
- Date of report
- 24 January 2019
- Coroner
- Sarah Bourke
- Coroner area
- London Inner (North)
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: 21 Mar 2019 (estimated).
Sent to
- North East London NHS Trust