Mental Health Failures and Suicide: Key Findings from a Clinical Negligence Inquest

The Deceased died by suicide in early 2022. Forbes Solicitors represented the dependant family, including children, spouse and elderly parents for whom the Deceased would have cared. At age 40, the Deceased held a senior position in a pharmaceutical company. Promotion at work extended responsibility during long hours. There was no history of mental illness before the diagnosis of First Episode Psychosis. In the week leading up to the death, the Deceased had little sleep.

After experiencing low mood and reporting suicidal ideation, the Deceased attended A&E via ambulance in Blackpool. Whilst in the ambulance, the Deceased spoke to paramedics. The account of what was said evolved through triage, resulting in his arrest. The Deceased wrongly thought devices had been hacked, placing the family in danger. The Deceased was reviewed by a psychiatrist and deemed to have capacity and to be fit for discharge. Upon returning home, the behaviour became increasingly bizarre with delusional thoughts. The family GP would not see the Deceased the same day, and the family were given the crisis team number.

In need of face-to-face review, the Deceased was accompanied to a walk-in centre where a GP first suspected First Episode Psychosis. The Deceased was referred to the Home Treatment Team for assessment after lengthy triage and was not seen in accordance with the standard operating procedure (SOP) for First Onset Psychosis (FOP). FOP presents a significant suicide risk, and when a patient presents with these symptoms, they should have an emergency assessment by a psychiatrist or their deputy on the day of presentation. From when FOP was diagnosed on 25th January, there was no assessment before the fatal self-harm on 26th January. Criticisms were made in the pleaded case of a cascade of failures.

Instead, the Deceased was sent home to be cared for by the family despite increasing delusions, sleep deprivation and escalating suicide risk. The Deceased erroneously believed that there was surveillance being undertaken by the police in an adjacent property. None of which was true. There was no prescription of sedatives, which would have helped to reduce the escalating anxiety.

A 5-day Article 2 inquest was arranged, and the Lancashire and South Cumbria Trust produced a 552-page investigation. They concluded that the staff were unaware of their own SOP for the management of FOP. The Deceased was not admitted to the hospital or detained. A psychiatrist did not assess his capacity. The hospital maintained throughout that even if the Deceased should have been detained, there were no beds anywhere in the country.

Coroner’s Conclusions

I. A failure by the mental health practitioner at the hospital to pass information on to the police regarding the rationale for discharge from the hospital

II. A below-standard handover by the Home Treatment Team practitioner to the Liaison and Diversion team at the police station

III. Inaccurate recording on care records by the home treatment team practitioner at the police station

IV. Failure to pass on information by the arresting officer to the custody sergeant in relation to suicidal ideation.

V. A failure by the police to appropriately raise concerns about the deceased’s behaviour whilst in police custody

VI. Failing to arrange an appropriate mental health assessment on the day when the First Onset Psychosis was suspected

VII. Failure to arrange an appointment with a consultant psychiatrist or their deputy on the day when the First Onset Psychosis was suspected

VIII. A failure to consider the prescription of medication after an initial prescription was consumed before expected

IX. A delay in referring the Deceased to the Home Treatment Team, resulting in a delay in receipt of  input from that team

X. Failure to arrange an appointment with a consultant psychiatrist or their deputy on the second day when First Onset Psychosis was suspected

XI. A failure to appropriately consider an admission to a mental health hospital when there was clear evidence of a mental health crisis.

On the day before the Joint Settlement Meeting, the Defendant served an abstract from an expert medical report suggesting the correct diagnosis for the Deceased was schizophrenia. The life expectancy for a patient with this diagnosis is less favourable. The application of this label was resisted by the Claimant’s expert, who recognised that there had been no previous mental health history and that it was not in the demographic.

The likelihood of returning to a high-powered job was scrutinised, and a change in lifestyle and a change in job role to a less stressful job were likely. Despite damning submissions from the coroner, the hospital did not accept the findings as indicative of negligence.

Liability for the death was denied throughout, even at the Joint Settlement Meeting. Yet, in the absence of any admission of fault, the Defendant made an offer of £750,000, which was later approved by the Court. The Heads of Loss included a bereavement award, damages for the injury to reflect pain and suffering, funeral expenses and past and future financial dependency on earnings and pension. A care report from a nursing expert set out services dependency for the children and elderly parents, including DIY and dog walking.

Speak to Our Clinical Negligence Team
At Forbes Solicitors, our specialist team offers expert legal advice to individuals whose loved ones have been harmed as a result of a healthcare professional’s failure to prevent suicide. Our team will review your circumstances and advise on the strength of your potential claim. We support clients nationwide and offer appointments via phone, video or at any of our UK offices. To find out how we can assist you, please contact our Clinical Negligence specialists today.