Source · Prevention of Future Deaths
Robert Anstice
Ref: 2015-0014
Date: 16 Jan 2015
Coroner: Jacqueline Lake
Area: Norfolk
Responses identified: 0 / 1
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Critical recommendations for support and care coordination were not actioned, and communication breakdowns meant team members were unaware of appointments. The patient was discharged despite difficulties in engagement and unmet practical needs.
Date
16 Jan 2015
56-day deadline
13 Mar 2015
Responses identified
0 of 1
Coroner's concerns
Critical recommendations for support and care coordination were not actioned, and communication breakdowns meant team members were unaware of appointments. The patient was discharged despite difficulties in engagement and unmet practical needs.
View full coroner's concerns
(1) On 12 August 2014 Psychiatrist recommended Mr Anstice would benefit from a Support Worker and/or Care Co-Ordinator – this was not actioned. The reason for this is not known – it was indicated this may be due to an administrative problem;
(2) It was recommended a referral be made for a Carer’s Assessment on 1 September 2014. It is not clear this referral was made. Even if it had been made there would be difficulties with assessment and provision of the service in view of the fact Mr Anstice resided in Norfolk and the service would be provided by Suffolk MH Team
(3) The appointment arranged with the Psychiatrist for 12 November 2014 was not known by other members of the Team, despite Team Meetings being in place to discuss Mr Anstice’s care.
(4) It was recommended to Mr Anstice he attend Group sessions to help overcome feelings of social isolation, whilst being unaware as to whether Mr Anstice was physically able to attend those Group sessions. He did not have the transport or means to attend such groups.
(5) When it became known to the IDT that Mr Anstice did not have the transport or means to attend the Groups, consideration was given as to how to help him overcome those practical difficulties but Mr Anstice was not informed that help was being considered.
(6) Mr Anstice was discharged from Bury North IDT on 17 September 2014, being invited to attend Groups and having attended one on the 5 September 2014. However IDT were unable to speak with Mr Anstice by telephone on 5 September 2014, 8 September 2014 (tried 3 times) and he did not attend Group session on 12 September 2014.
(7) At the time of Mr Anstice’s discharge from Bury North IDT, IDT were unaware Mr Anstice had an appointment with a Psychiatrist on 12 November 2014.
(2) It was recommended a referral be made for a Carer’s Assessment on 1 September 2014. It is not clear this referral was made. Even if it had been made there would be difficulties with assessment and provision of the service in view of the fact Mr Anstice resided in Norfolk and the service would be provided by Suffolk MH Team
(3) The appointment arranged with the Psychiatrist for 12 November 2014 was not known by other members of the Team, despite Team Meetings being in place to discuss Mr Anstice’s care.
(4) It was recommended to Mr Anstice he attend Group sessions to help overcome feelings of social isolation, whilst being unaware as to whether Mr Anstice was physically able to attend those Group sessions. He did not have the transport or means to attend such groups.
(5) When it became known to the IDT that Mr Anstice did not have the transport or means to attend the Groups, consideration was given as to how to help him overcome those practical difficulties but Mr Anstice was not informed that help was being considered.
(6) Mr Anstice was discharged from Bury North IDT on 17 September 2014, being invited to attend Groups and having attended one on the 5 September 2014. However IDT were unable to speak with Mr Anstice by telephone on 5 September 2014, 8 September 2014 (tried 3 times) and he did not attend Group session on 12 September 2014.
(7) At the time of Mr Anstice’s discharge from Bury North IDT, IDT were unaware Mr Anstice had an appointment with a Psychiatrist on 12 November 2014.
Report sections
Investigation and inquest
On 29 September 2014 I commenced an investigation into the death of Mark Robert Anstice, aged 38 years. The investigation concluded at the end of the inquest on 13 January 2015. The conclusion of the inquest was medical cause of death: 1a) Fatal compression to the neck and narrative conclusion: Mr Anstice hanged himself. His intention at the time is not known.
Circumstances of the death
Mr Anstice had a history of mental health and social problems, leading to previous self harm. He moved to Norfolk in 2012. Towards end 2013/beginning 2014 his mental health deteriorated with feelings of isolation. He became more withdrawn. In July 2014 he considered taking his own life and was referred to the Access and Assessment Team (AAT). Due to further problems, he was assessed under the MH Act on 3 August 2014. He was seen by Psychiatrist on 12 August 2014, who recommended a Support Worker/Care Co-Ordinator and review. There was an overdose on 27 August 2014, when he was admitted to WSH as a voluntary patient. He was discharged 3 September 2014, to Bury North IDT. Mr Anstice did attend a Group Session on 5 September 2014, but otherwise was not spoken to by Bury North IDT despite attempts made to telephone on 5 and 8th September 2014. Mr Anstice did not attend a Group Session on 12 September 2014. On 17 September 2014, Mr Anstice was discharged from Bury North IDT to the care of GP. An Appointment with the Psychiatrist was brought forward to 8 October 2014 at request of Mr Anstice’s partner. On 25 September 2014 Mr Anstice was reported as a missing person. He was found hanged on 27 September 2014.
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Report details
- Reference
- 2015-0014
- Date of report
- 16 January 2015
- Coroner
- Jacqueline Lake
- Coroner area
- Norfolk
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: 13 Mar 2015.
Sent to
- Norfolk and Suffolk NHS Foundation Trust