Source · Prevention of Future Deaths
Alexander Holt
Ref: 2015-0040
Date: 3 Feb 2015
Coroner: Christopher Dorries
Area: South Yorkshire (West)
Responses identified: 0 / 1
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Failures included not challenging minimised suicidal intent, providing intended treatment, ensuring continuity of care, and maintaining information flow, leading to inadequate risk assessment and a broken referral process.
Date
3 Feb 2015
56-day deadline
31 Mar 2015
Responses identified
0 of 1
Coroner's concerns
Failures included not challenging minimised suicidal intent, providing intended treatment, ensuring continuity of care, and maintaining information flow, leading to inadequate risk assessment and a broken referral process.
View full coroner's concerns
(1) The prospect that Mr Holt was minimising or concealing the true extent of his suicidal intent should have been subject to a greater degree of challenge and his parent's fears in this regard should have carried more weight (2) It was accepted at the inquest that there was a failure to provide the type of treatment originally intended.
(3) The referral process for SORT failed to materialise despite repeated concerns expressed.
(4) Importantly, Mr Holt's parents described how too many people became involved in his care over a period preventing the necessary degree of continuity.
(5) There was a failure to maintain a good flow of information. Most strikingly, the staff at Beaufort Road were not advised of Mr Holt's most recent attempt at self-harm (by overdose of his medication) and were thus unaware of the degree of risk when he returned to that address where support would have been available.
(6) It was accepted at the inquest that more could have been taken into account in risk assessing Mr Holt.
(3) The referral process for SORT failed to materialise despite repeated concerns expressed.
(4) Importantly, Mr Holt's parents described how too many people became involved in his care over a period preventing the necessary degree of continuity.
(5) There was a failure to maintain a good flow of information. Most strikingly, the staff at Beaufort Road were not advised of Mr Holt's most recent attempt at self-harm (by overdose of his medication) and were thus unaware of the degree of risk when he returned to that address where support would have been available.
(6) It was accepted at the inquest that more could have been taken into account in risk assessing Mr Holt.
Report sections
Investigation and inquest
On 19 December 2013 I commenced an investigation into the death of Alexander Matthew Holt (aged 30). The investigation concluded at the end of the inquest on 19 September 2014. The conclusion of the inquest was that Mr Holt took his own life, asphyxiating himself by a ligature in his accommodation at Beaufort Rd, Sheffield on 16/17 December 2013.
Circumstances of the death
Mr Holt was well known to the Health & Social Care Trust. He had a history of attempts at self-harm, some of which were very serious events. His parents had expressed clear and sensible views as to the form of treatment that would most likely be beneficial for their son. In particular, it had previously been intended by his then consultant that there would be assertive community support which never took place. His parents described their son as 'losing hope' at the lack of meaningful program available. A short period before his death Mr Holt took an overdose of medication but this was not communicated to those supervising the accommodation where he was staying. Mr Holt lost his life by an act that was impulsive but deliberate.
Copies sent to
and to the Care Quality Commission
Similar PFD reports
Report details
- Reference
- 2015-0040
- Date of report
- 3 February 2015
- Coroner
- Christopher Dorries
- Coroner area
- South Yorkshire (West)
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 Mar 2015.
Sent to
- Sheffield Health and Social Care Trust