Source · Prevention of Future Deaths

John Jones

Ref: 2016-0327 Date: 5 Sep 2016 Coroner: Robert Sowersby Area: Avon Responses identified: 0 / 1 View PDF

A significant delay in notifying the GP of patient discharge from the Crisis Team left the patient without community support. Crisis Team training lacked clear communication protocols for such handovers.

Date 5 Sep 2016
56-day deadline 31 Oct 2016
Responses identified 0 of 1
Mental Health related deaths

Coroner's concerns

AI summary
A significant delay in notifying the GP of patient discharge from the Crisis Team left the patient without community support. Crisis Team training lacked clear communication protocols for such handovers.
View full coroner's concerns
Mr Jones was initially referred to the Crisis Team because his GP believed that Mr (1) Jones' suicide risk coula not be safely managed within the community: When Mr Jones was in due course discharged from the Crisis Team'8 care it was Sproxenately a week before his GP was notified of that discharge. That notification was received by fax (3a SThis meant that during the important period immediately after discharge from the Crisis Team's care there was a period of approximately a week when Mr Jones was (notionally) back under the care of his GP but his GP was unaware that this was the case: this meant that Mr Jones would have had no support within the community during this period aside from a single follow up post-discharge call from the Crisis team: (4) In evidence the GP indicated that it would have been helpful to have been contacted by telephone at the time of Mr Jones'_discharge andnotified of it

(6) It did not appear to me that there was any clear provision within the Crisis Team $ training structure protocols for the sort of communication envisaged by Mr Jones' GP.

Report sections

Investigation and inquest
On 16"h February 2016 an investigation commenced into the death of John Gerard JONES, Aged 57 . The investigation concluded at the end of the inquest on August 2016_ The conclusion of the inquest was that the medical cause of death was la Drowning And the conclusion was Suicide
Circumstances of the death
Mr: Jones had been receiving support because of his perceived risk of suicide from late December 2015. On 2 January 2016 he was assessed and admission to hospital was recommended by approved psychiatrists_ but the decision was taken not to admit him; On 13 January 2016 he was discharged from further support and on or around February 2016 he took his own life by drowning himself in the River Avon:
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
2016-0327
Date of report
5 September 2016
Coroner
Robert Sowersby
Coroner area
Avon

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: 31 Oct 2016.

Sent to

Avon and Wiltshire Mental Health Partnership NHS Trust

Part of a series

2 reports

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