Source · Prevention of Future Deaths

Graham Darby

Ref: 2014-0367 Date: 24 Jul 2014 Coroner: Gail Elliman Area: London North Responses identified: 0 / 3 View PDF

A crucial communication breakdown occurred as a patient's explicit suicide threat regarding eviction was not adequately flagged to the housing provider by mental health services. This prevented the housing provider from taking appropriate preventative actions.

Date 24 Jul 2014
56-day deadline 18 Sep 2014 est.
Responses identified 0 of 3
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
A crucial communication breakdown occurred as a patient's explicit suicide threat regarding eviction was not adequately flagged to the housing provider by mental health services. This prevented the housing provider from taking appropriate preventative actions.
View full coroner's concerns
That there were a number of agencies involved in both trying to assist Mr Darby and to deal with his anti-social behaviour (which led to the eviction). That although information was passed on generally between agencies and that communication was ongoing about Mr Darby, the evidence disclosed that one significant piece of information was not flagged up as it was not made sufficiently clear to Family Mosaic who were responsible for his housing and eviction. This was that the psychiatrist from ARC made a specific observation that Mr Darby had said that he had a knife and a rope in his property and would take his own life if evicted. The witness from Family Mosaic said that this particular piece of information was not passed on and that if it had been different actions may have been taken. Such direct threats should be flagged up in similar circumstances.

Report sections

Investigation and inquest
On 24 June 2013 I commenced an investigation into the death of Graham Darby, born on 18 July 1956. The investigation concluded at the end of the inquest on 31 October 2013. The conclusion of the inquest was that the medical cause of death was suspension by ligature and that his death was a suicide.
Circumstances of the death
I concluded that Graham Darby had a mental and behavioural disorder due to alcohol dependence and that the day after having been evicted from his home he was found dead at his home address having forcibly re-entered the property.

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Report details

Reference
2014-0367
Date of report
24 July 2014
Coroner
Gail Elliman
Coroner area
London North

Responses identified

Responses identified 0 of 3
3 responses not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 18 Sep 2014 (estimated).

Sent to

East London NHS Foundation Trust
Family Mosaic
Hackney Alcohol Recovery Centre

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