Mental Health and Failure to Prevent Suicide

The sad case documented by the BBC of Gary Mavin highlights a publicised case where multiple failings in mental health led to the death of a 54 year old man. In this example there was a misdiagnosis by a consultant psychiatrist.

'Leah Mavin told the BBC her 54 year old husband entered the Priory after being diagnosed with psychosis at the city's Queens Medical Centre (QMC) following an overdose.

However, his inquest heard the QMC's diagnosis was not recorded on Mr Marvin's notes.

At the Priory, he told staff he could hear voices and feared being discharged, as he thought a gang was going to attack him at home.

His inquest heard Dr Daniel Moldavsky, who had been assigned Mr Marvin's case, ignored this, believing Mr Mavin, a father of-three was "malingering" to get better housing.

"It is shocking to think the experts could get is so wrong," said Mrs Mavin.

"Nothing was done to treat him".

Nottingham's Assistant Coroner Laurinda Bower said this misdiagnosis resulted in him not being given the right treatment.

Medication and treatment could have helped the deceased very effectively had it been given.

Suicide does not necessarily need to have been foreseen

Case law dictates that you do not have to foresee suicide if physical injury can be foreseen.

In the case of Corr v IBC (2008) a severe injury at work led to depression and eventual suicide. If some damage is foreseen as a result of a breach, the precise form it takes needs not be.

In that case it was held that it was an act performed because of his psychological condition which the breach of duty by his employer caused. His suicide was not an intervening event but amounted to an independent cause.

Lord Bingham recorded; 'it was the response of a man suffering from a severely depressive illness… such illness being, as is accepted, a consequence of the employer's tort.

How a case is determined?

There can be a whole range of reasons for suicide and it is important to consider whether there has been a breach of duty. Some common ones are:

• Failure to risk assess a patient.

• Failure to involve the family in what was going on.

• Premature ending of treatment.

• Failure to provide treatment.

• Inadequate observations.

• Inadequate assessment for discharge.

• No direct questioning.

• Failure to identify masking of symptoms.

• Failure to consider history/previous events.

• Failure to consider circumstances/indirect evidence.

• Family concerns.

• Failure to identify psychosis.

• Failure to address and treat psychosis.

• Failure to update a risk assessment.

• Failure to undertake DYNAMIC RA.

The Human Impact

Mental health and wellbeing should be at the forefront of work and educational agendas because of the pressures of modern life. NHS and private providers must adapt accordingly to prevent the catastrophic consequences. Bereavement, dependency, guilt, sadness, psychological distress of the loved ones left behind in addition to the suffering of the deceased whilst alive.