Source · Prevention of Future Deaths

Ricky Anderson

Ref: 2013-0227 Date: 9 Sep 2013 Coroner: Patricia Harding Area: Mid Kent and Medway Responses identified: 0 / 2 View PDF

Mental health services failed to inform the GP of hospital admissions, relied excessively on family for post-discharge monitoring, and discharged a patient early without a care plan.

Date 9 Sep 2013
56-day deadline 23 Mar 2014 est.
Responses identified 0 of 2
Mental Health related deaths

Coroner's concerns

AI summary
Mental health services failed to inform the GP of hospital admissions, relied excessively on family for post-discharge monitoring, and discharged a patient early without a care plan.
View full coroner's concerns
(1) It was established in evidence at the inquest that practitioners from the Kent Medway NHS and Social Care Partnership Trust did not inform Mr. Anderson's GP of his involvement with primary care on either occasion he was admitted to hospital, resulting in him not being able to obtain a further supply of medication without the intervention of his family (2) Evidence was given at the Inquest that following Mr: Anderson's discharge from hospital a number of attempts were made to contact him to assess his wellbeing and needs. Although Mr. Anderson was spoken to briefly, it was accepted by the Trust that too much reliance was placed on information from family members_ As a result Mr. Anderson had virtually no contact with the Access team prior to his death: understand that a practice note has recently been drafted which is intended to be used as guidance Mr: Anderson's discharge from hospital occurred at an earlier stage than had been planned as he wished to leave and was deemed safe to do so_ As a consequence, care plan had not been put in place to establish his needs heard evidence that following Mr: Anderson's death procedures have been in place to ensure that this situation does not reoccur

Report sections

Investigation and inquest
On 23rd 2012 commenced an investigation into the death of Ricky Anderson. The investigation concluded at the end of the inquest on 27th August 2013. The conclusion of the inquest was that Ricky Anderson killed himself while suffering from depression by means of suspension
Circumstances of the death
On the 29th March 2012 Ricky Anderson was informally admitted to hospital experiencing command hallucinations with suicidal thoughts_ As his symptoms coincided with substance misuse it was felt they were drug related rather than representing psychotic illness He was discharged on the 5" April 2012 but readmitted two days later when his symptoms returned: He continued to express suicidal and delusional thoughts intermittently whilst at hospital and was discharged earlier than planned on the 16"h April 2012 with medication which had improved his symptoms_ He went to stay with a relative for a short time but did not see anyone from the Access team after his return to the area. On the morning of the 21s May 2012 Ricky Anderson was found at Chatham Cemetery suspended from a tree_ There was no evidence of third party involvement;, a note in his handwriting was found on his person indicating his reasons for taking his life
Action should be taken
In my opinion action should be taken to prevent future deaths believe your organisation] have the power to take such action_

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Report details

Reference
2013-0227
Date of report
9 September 2013
Coroner
Patricia Harding
Coroner area
Mid Kent and Medway

Responses identified

Responses identified 0 of 2
2 responses not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 23 Mar 2014 (estimated).

Sent to

Kent and Medway NHS
Social Care Partnership Trust

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