Source · Prevention of Future Deaths

Nathan Lowe

Ref: 2016-wp25387 Date: 19 Aug 2016 Coroner: Roy Palmer Area: City of London 1 response identified · 1 indexed addressee View PDF

AI-generated concerns summaryThe coroner raised concerns regarding whether more active efforts should have been made to contact the patient between 10th March and 12th May, considering his illness and non-compliance with follow-up.

Date 19 Aug 2016

56-day deadline 19 Oct 2016 stated in the report

Responses identified 1 of 1

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

Coroner's concerns

AI summary

The coroner raised concerns regarding whether more active efforts should have been made to contact the patient between 10th March and 12th May, considering his illness and non-compliance with follow-up.

View full coroner's concerns

Whether or not more should have been done to make contact with the patient between 10th March and 12th May given the nature of his illness and the fact of his non-compliance with follow up. Such consideration is relevant to a Coroner's duty in connection with the prevention of future deaths

City of London Coroner's Court, Walbrook Wharf, 78-83 Upper Thames Street, London, EC4R 3TD Tel 020 7332 1598 | Fax 020 7332 1800

Responses

1 respondent

Nathan Lowe

NHS Trust

PDF

AI-classified response stance Action Taken

AI-generated response summary

• The Trust conducted a serious incident investigation, which identified areas for improved practice and missed opportunities for more assertive follow-up post-discharge. • An action plan was implemented to address these learning points, and learning has been shared across Trust teams. • Specific actions taken include improved communication in multi-disciplinary team meetings, enhanced leadership oversight, and clearer recording of actions and timeframes for service user follow-up.

Report sections

Investigation and inquest

On 12/05/2016 I commenced an investigation into the death of Nathan Anthony Lowe, 45. The investigation concluded with a medical cause of death given as 1a) multiple injuries including skull fracture. At the inquest held on 19 August 2016, the conclusion was Suicide.

Circumstances of the death

Nathan LOWE was discharged from a Section 2 Mental Health Act Order and from Hospital on or around 9th October 2015. He was to be followed up in the community by a psychiatric nurse The last "face to face" contact between the patient and nurse was on 10th March 2016. Mr Lowe fell to his death in central London on 12th May 2016. The psychiatric nurse made several attempts to contact Mr Lowe between 10th March and 12th May including a referral to the multidisciplinary team and through the Multi Agency Public Protection Arrangements team

Similar PFD reports

Shared signals

Report details

Reference: 2016-wp25387
Date of report: 19 August 2016
Coroner: Roy Palmer
Coroner area: City of London

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 19 Oct 2016 (stated in the report).

Sent to

Hertfordshire Partnership University NHS Foundation Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

Contains public sector information licensed under the Open Government Licence v3.0.