Source · Prevention of Future Deaths
Jack Susianta
Ref: 2016-0176
Date: 6 May 2016
Coroner: Mary Hassell
Area: London Inner North
Responses identified: 0 / 1
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Critical information about Jack's expected recovery, symptom recurrence, and urgent help protocols was not communicated to his family, preventing them from seeking timely hospital readmission.
Date
6 May 2016
56-day deadline
1 Jul 2016 est.
Responses identified
0 of 1
Coroner's concerns
Critical information about Jack's expected recovery, symptom recurrence, and urgent help protocols was not communicated to his family, preventing them from seeking timely hospital readmission.
View full coroner's concerns
The consultant psychiatrist who assessed Jack on the morning of Tuesday, 28 July, fully expected him to continue to improve. Whilst she was concerned that he might take drugs again, she thought that he had recovered from this psychotic episode.
However, she did not communicate to his family:
- first and foremost, the fact that she expected him now to be free from all psychotic symptoms;
- second, that any recurrence of these symptoms would be a cause for significant concern and potentially immediate action;
- thirdly, in exactly what circumstances professional help should be sought on an urgent basis and how to go about this.
Jack’s family were very worried indeed about his condition. However, because they had not been given the clinical expectation, they did not know that they could/should take him back to hospital, even though he had been discharged only hours before.
By the time they rang police that afternoon, Jack was on the point of leaving the house. However, they had felt something was wrong from the evening before. His brother had even trawled the internet looking for appropriate advice.
However, she did not communicate to his family:
- first and foremost, the fact that she expected him now to be free from all psychotic symptoms;
- second, that any recurrence of these symptoms would be a cause for significant concern and potentially immediate action;
- thirdly, in exactly what circumstances professional help should be sought on an urgent basis and how to go about this.
Jack’s family were very worried indeed about his condition. However, because they had not been given the clinical expectation, they did not know that they could/should take him back to hospital, even though he had been discharged only hours before.
By the time they rang police that afternoon, Jack was on the point of leaving the house. However, they had felt something was wrong from the evening before. His brother had even trawled the internet looking for appropriate advice.
Report sections
Investigation and inquest
On 3 August 2015, one of my assistant coroners, William Dolman, commenced an investigation into the death of Jack Susianta, aged 17 years. The investigation concluded at the end of the inquest on 29 April 2016. At inquest, the jury made a determination that death arose as a result of a drug related accident.
Circumstances of the death
Jack was a 17 year old boy who suffered a drug related psychotic episode after having taken cannabis and ecstasy at a music festival. He was detained by police under s136 of the Mental Health Act and taken to Homerton University Hospital at around 3am on Tuesday, 28 July 2015. Following assessment, he was diagnosed as having suffered a substance related psychosis, and was discharged soon after 7am with a plan for follow up.
However, after discharge Jack’s condition deteriorated. His family recognised this, but did not know how best to help him, other than to stay close and offer love & support.
The following afternoon, Wednesday, 29 July, his family called police again but, during the call, he left the family home by jumping through a window. Police attended and he was deemed a high risk missing person. During a line search, police officers saw him running towards a river. One gave chase and nearly caught him, but Jack dodged and then jumped in the river. He submerged and drowned.
However, after discharge Jack’s condition deteriorated. His family recognised this, but did not know how best to help him, other than to stay close and offer love & support.
The following afternoon, Wednesday, 29 July, his family called police again but, during the call, he left the family home by jumping through a window. Police attended and he was deemed a high risk missing person. During a line search, police officers saw him running towards a river. One gave chase and nearly caught him, but Jack dodged and then jumped in the river. He submerged and drowned.
Copies sent to
Homerton University Hospital NHS TrustHackney Child Death Overview Panel
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Report details
- Reference
- 2016-0176
- Date of report
- 6 May 2016
- Coroner
- Mary Hassell
- 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: 1 Jul 2016 (estimated).
Sent to
- East London NHS Foundation Trust