Dean Hayden

[250-word statement addressing what circumstances of the death have led to the coroner’s  concern, and why the coroner thinks the person to whom the report is directed is responsible  for taking action to prevent future deaths. This statement must not propose what action should  be taken, as coroners cannot make recommendations]. 

Mr Hayden experienced a number of discharges from specialist mental health services back to the care of his GP. Of particular concern was the contact of 13 March 2025, when he  telephoned the Mental Health Crisis Team expressing suicidal thoughts, describing actions he  was considering to end his life and requesting to be sectioned because he feared acting upon  those thoughts. Following assessment at the hospital, it was recorded that he did not have  active plans or intent at that time and he was discharged, partly because he was unwilling to  engage with addiction services and did not wish to be referred to the Community Mental Health Team. 

Evidence from the Consultant Psychiatrist was that Mr Hayden was regarded as a patient who  posed a long-term risk of suicide, suffered chronic suicidal ideation and was difficult to  manage. The Consultant Psychiatrist accepted that continuity of care through the Community  Mental Health Team may have been more beneficial than repeated discharge back to primary  care and, with hindsight, accepted that the decision to discharge Mr Hayden on 13 March  2025 was probably the wrong decision. 

The concern is whether current assessment and discharge processes adequately protect  patients with chronic suicidality, previous serious suicide attempts and expressed suicidal  intent, and whether greater continuity of specialist mental health care is required for such high-risk patients to reduce the risk of future deaths.