James Savo

On 06/12/2013 commenced an investigation into the death of James Savo, aged 27 . The investigation concluded at the end of the inquest on 01 June 2015. The conclusion of the inquest was a Narrative Conclusion Mr Savo's cause of death was Ia Hanging and the Narrative Conclusion is as follows "James Savo had a long standing history of depression: Following his first period of inpatient treatment he was discharged home on 29 November 2013. At the time of his discharge insufficient weight was attached to both the timing and nature of the home treatment team's input and also to family concerns and issues_ On balance this led to earlier discharge that should have been the case_ Mr Savo hanged himself in woodland off Scholes Lane on 3rd December 2013. Had Mr Savo not been discharged on 29 November 2013 it is unlikely that he would have died at the time he did.

Mr Savo had a standing history of depression_ In October 2013 he had his first period of inpatient treatment During that time there was a change in his anti-depressant; assessment on the ward and four periods of home leave; three of which were with his family the fourth period and, longest; was with a friend There was insufficient communication with the family regarding Mr Savo s presentation and their views on home leave. The last direct Home Treatment Team involvement was some 9 prior to discharge when there was still issues with Mr Savo's home environment; family tensions There was a need for on-going assessment of his response to medication: He had continuing suicidal thoughts. There was noted to be improvement in the ward setting although he was not as well whilst at home. After a seven period of leave with a friend Mr Savo returned to the ward where he was then discharged back to his home environment; a Home Treatment Team representative was not present at this meeting: Their last involvement would have been documented in the computerised records; with the last assessment being some 9 days prior to discharge: There was no evidence of communication with the familylcarers at this time. Following Mr Savo's discharge there was a crisis situation 2 later where the decision was made to continue James' treatment in the community setting (whilst he remained at home) 4 days after discharge on the 3r December Mr Savo hanged himself:

In my opinion action should be taken to prevent future deaths and believe you The Chief Executive and Medical Director have the power t0 take such action.