Source · Prevention of Future Deaths

Daniel Collins

Ref: 2018-0283 Date: 14 Sep 2018 Coroner: James Bennett Area: Birmingham and Solihull Responses identified: 0 / 2 View PDF

A mental health service transferred a recently suicidal patient's care, requiring the patient to initiate contact with the new service, without proper handover or follow-up, risking loss of care during a crisis.

Date 14 Sep 2018
56-day deadline 9 Nov 2018
Responses identified 0 of 2
Hospital Death (Clinical Procedures and medical management) related deaths Suicide (from 2015)

Coroner's concerns

AI summary
A mental health service transferred a recently suicidal patient's care, requiring the patient to initiate contact with the new service, without proper handover or follow-up, risking loss of care during a crisis.
View full coroner's concerns
_ One mental health service, FTB crisis team, transferred necessary mental health care to a second service Living Well Consortium (LWC} , putting the responsibility of making contact on the patient (aged 22,and only 72 hours post-attempting to take his own life): The rational was "it is part of their recovery, empowers them and gives them choices" . FTB crisis team did not alert LWC to the transfer and did not follow up with LWC or the patient that contact had been made: There was/is no system in place to require FTB crisis team to notify LWC about the transfer or trigger a follow up with Lwc/the patient: Therefore, patients are at risk of being lost to the mental health service whilst in crisis/only recently out of crisis_

Report sections

Investigation and inquest
On 03/05/2018 commenced an investigation into the death of Daniel Hubert Collins The investigation concluded at the end ofan inquest on 31/08/18. The conclusion of the inquest was Suicide:
Circumstances of the death
The Deceased had no known mental health issues prior to attempting to take his own life via an overdose on 07/04/18 when he was admitted to Hospital. He reported being concerned about the poor health of relatives, that his relationship with his girlfriend had ended and the pressure of completing his degree He was assessed by RAID nurses on 8 and 9/04/18 and discharged from Hospital on 9/04/18,and because of his young age, was referred to the Forward Thinking Birmingham (FTB) crisis team. An FTB crisis team nurse attended his home on 10/04/18,assessed him, and discharged him from the FTB crisis team to mental health service counselling putting responsibility on the Deceased to make contact with them. There was no follow up from the FTB crisis team generally, or to check that he had contacted the counselling service: On 25/04/18 he attended a meeting requested by his university to discuss concerns about his wellbeing and mental health. On 26/04/18 he went missing and he was found deceased on 28/04/18 in an area of woodland in Moseley Bog having taken a deliberate overdose. Following post mortem the medical cause of death was determined to be:
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action_

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Report details

Reference
2018-0283
Date of report
14 September 2018
Coroner
James Bennett
Coroner area
Birmingham and Solihull

Responses identified

Responses identified 0 of 2
2 responses not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 9 Nov 2018.

Sent to

Birmingham and Solihull Clinical Commissioning Group
Birmingham Women’s and Children’s NHS Trust

Part of a series

2 reports
2014-0058 0 responses identified

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