What happened to B?
I recently represented the family of a man who tragically died by suicide following a period of significant mental health difficulty. The inquest into his death examined the circumstances leading up to his death and considered the care and support he received from his employer and healthcare professionals in the weeks before he died.
The man, who I will refer to as “B” to protect the privacy of his family, was a much-loved partner, father, son and friend. His death has had a devastating impact on those closest to him, including his partner, children and parents, who continue to live with the profound loss he has left behind.
In the months leading up to his death, B had been experiencing serious mental health struggles. Importantly, he sought help. He spoke openly with professionals about his deteriorating mental health, including thoughts of suicide and concerns about his own safety. Like many individuals who reach out for support, he trusted that by being honest about his feelings he would receive appropriate care, protection and understanding.
What happened during the Inquest?
The inquest process itself was lengthy and challenging for the family. They experienced a significant wait before the hearing could take place, during which time they were left with many unanswered questions about what had happened.
As is often the case in complex inquests, obtaining the relevant disclosure and documents also took time. I had to carefully review large volumes of records to piece together the chronology of events and identify the issues that required further scrutiny.
The inquest provided an important opportunity to ask those questions in a public forum and to examine the care that had been provided. Expert evidence heard during the proceedings raised concerns about aspects of the mental health assessment carried out shortly before B’s death, including whether sufficient information had been gathered about his history and the level of risk he was experiencing at the time.
Evidence was also heard about the pressures B had been facing in other areas of his life, including difficulties at work. While these issues formed part of the wider context of his circumstances, the inquest considered whether the professionals involved in B's care had obtained a full picture of his situation and whether those closest to him had been adequately listened to when concerns were raised.
The evidence explored whether opportunities may have been missed to identify the seriousness of the risks B was facing and to provide appropriate support.
What was the Coroner’s conclusion?
The Coroner concluded that the deterioration in B’s mental health was exacerbated after he ran out of his supply of Zopiclone (sleeping medication) and the inability, due to the GP surgery infrastructure issues and general lack of availability of GP appointments, to secure a further prescription or other course of action to aid his poor sleep.
In addition, the Coroner concluded that when B attended hospital again because of concerns for his welfare on the back of his deteriorating mental health and earlier attempts at self-harm, the assessment carried out failed to accurately capture his mental health history, including how he came to be at the hospital.
In particular, there was no examination of the Emergency Department held documentation or consideration of collateral history provided by his partner, neither of which factored into the assessment process.
Importantly, the Coroner concluded that had an accurate history been collected B – more likely than not – would have been urgently referred to the Intensive Service and it is unlikely he would have died when he did.
What happens now?
For families, the inquest process is not about apportioning blame but about understanding what happened and ensuring that any learning is identified. In cases such as this, careful disclosure and the ability to ask the right questions of witnesses and experts can be critical in helping families obtain the clarity they need.
While nothing can undo the loss experienced by B’s family, the inquest has helped to provide a clearer understanding of the circumstances surrounding his death. It also highlights the importance of ensuring that individuals who speak openly about suicidal thoughts are fully listened to, carefully assessed, and provided with appropriate support.
Further, the inquest highlighted the importance of ensuring that individuals presenting in crisis are assessed using all available sources of information, including hospital records and the observations of those closest to them. The findings also underline the impact that barriers to accessing primary care and continuity of medication can have for individuals experiencing significant mental health difficulties.
I hope that the findings from this inquest will contribute to ongoing reflection and improvements in how people experiencing acute mental health difficulties are assessed and supported by services.
Where can you access support?
If you are struggling, or if you are concerned about one of your loved ones, you can contact the following charities for support:
- Samaritans - Tel: 116 123 (free to call)
If you are experiencing a mental health crisis and need help immediately because you may hurt yourself or someone else, call 999.
Hannah Carr, Director Specialist Medical Negligence Solicitor from MDS who represented the family, said “Inquests play a vital role in helping families understand what happened to their loved one and in identifying lessons that may help prevent similar tragedies in the future. This case highlights how important it is that people who speak openly about their mental health are properly listened to, thoroughly assessed and able to access timely care.
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