Coroner Urges NHS Trust To Learn Lessons From Tragic Suicide Of Depressed Father

A Coroner has welcomed the Trust’s desire to improve communication between different suppliers of Mental Health Services. Hopefully the steps will prevent future deaths after a father-of-three committed suicide, despite weeks of desperate pleas to his GP and mental health services for help in the months before his death.

Alvan Brown hanged himself on 16 April 2013 at his home in Retford, following a long history of depression, and his family has instructed medical law experts at Irwin Mitchell to investigate a series of ‘shambolic errors’ made by Nottinghamshire Healthcare NHS Trust who run Let’s Talk Wellbeing and Mental Health Services for Older People who were responsible for his care.

Mr Brown contacted or attended one of the above healthcare providers a total of 10 times throughout January and February 2013 but this was not recognised as a plea for help by any of the services.

An inquest at Nottingham Coroner’s Court which concluded today (8 April) heard that there was a delay of five days in an urgent referral, which was made by Mr Brown’s GP, being passed to the correct department at Bassetlaw Hospital so that when a call was finally made to arrange for Mr Brown to see a specialist, it was too late – the 65-year-old had taken his life hours before.

HM Coroner Ms Jane Gillespie heard:
• An appointment on 10 April with Mr Brown’s GP at Bridgegate surgery resulted in an urgent referral being drafted to a specialist mental health team, but there was an unexplained delay of a day in drafting and faxing it to the correct team;
• The urgent referral was then faxed to the wrong number;
• When it did finally reach the hospital it was left in a pile of routine referrals as there was no system in place to separate urgent matters;
• The referral was not reviewed by the correct mental health team until 16 April.

The Coroner’s Court was told that had the fax arrived at the correct department on 11 April, the mental health team would have attempted to make contact with Mr Brown within 24 hours. The coroner was satisfied had the referral been received he would have been seen within 3-5 days. The delay meant Mr Brown was left without any contact from the professionals over the weekend and into the following week - a delay of five days. The coroner was unable to say whether that action would have prevented the tragedy.

The Coroner adjourned the inquest on 4 February 2014 and asked the Nottinghamshire Healthcare NHS Trust to address her concerns about the access and exchange of information between the different Mental Health Services and whether action could be taken so that information could be accessed through their different IT systems.

Professor Christopher Packham the Associate Medical Director provided a statement to the court to say that it would be difficult for clinical staff to access every patient contact because of volume, which highlighted the importance of the GP role in actually identifying and highlighting concerns. In Mr Brown’s case, the coroner was concerned that the fact Mr Brown had contacted the Bassetlaw crisis team in February 2013 and the fact that he had seen his GP after writing a suicide note, had not been brought to the attention of the team at “Lets Talk Wellbeing” and that may have influenced their management plan.

Expert Opinion

Alvan and his family did all they could to seek out urgent assistance from the psychiatric services. He had a long history of anxiety and depression which worsened over the last few months of his life. Alvan had noticed the warning signs early and sought help.

“Alvan's GP referred him to the local mental health services but unfortunately it was at this stage where the loss of vital information and a series of shambolic communication errors let Mr Brown and his family down.

“The Coroner welcomed the developments and changes within the Trust which included GPs being made aware of the correct number to fax urgent referrals, training so that staff can recognise risk and an awareness of family provided information when judging risk and response. She also asked that the Trust keep her updated of the changes.

“The family are now considering a Civil Claim against the Trust. It is too late to change the outcome in their case, but the family hope that the changes will avoid this tragedy happening again.”
Rachelle Mahapatra - Partner

In August 2012, Alvan retired from his job as a nursing assistant at Nottinghamshire Healthcare NHS Trust and within three months he recognised his symptoms of depression and saw his GP over concerns about his mental health. A stress control course in a group setting was recommended in January 2013 and he was advised that he would receive six sessions starting at the end of February.

But he began to express suicidal intentions to his family and visited his local A&E department at Bassetlaw Hospital on 4 February 2013 for help. He asked to be admitted to the psychiatry ward where he had previously been treated but was refused admission the basis of his age. As he had recently turned 65 he needed to be referred to Mental Health Services for Older People. No referral was made by the hospital; he was told to attend the stress control course.

Following the stress control course Mr Brown’s mental health was assessed by the course co-ordinator on 4 April. The records show his mental health had deteriorated significantly and the Coroner was told Mr Brown would have been suitable for one-to-one therapy but the referral process would have taken 10 working days to arrange through the GP.

Throughout the course of group therapy the co-ordinator remained unaware of Mr Brown’s whole mental health history and had no knowledge of his A&E visit and plea for help on 4 February.

Tim Brown, Alvan’s son, from Scarborough, said: “Hearing the outcome of the inquest was a moment of the most terrible mixed emotions. We are pleased that the Coroner conducted a thorough investigation and recognised the failings of the Trust, but nothing could make bearable the fact he is gone forever from our lives and that his death could have been prevented.

“It seems absolutely unacceptable that in 2013/14 we are discussing the wrong fax number being one of the reasons for my father’s urgent referral not being acted upon.

My father was very loving father and a doting grandfather who cared deeply for his family. He was a keen classic motorcyclist and tall-ship sailor. He loved life and travelled regularly. We were heartened by the attendance of over 300 friends at his funeral.

We believe my father and my family were badly let down because of poor process and bad judgement by all the healthcare professionals involved, we tried on numerous occasions to warn the GP about the severity of his depression but none of our concerns were ever acted upon.

“It is a sad irony that one of the organisations that failed my father is Nottinghamshire Healthcare NHS Trust, for whom my father had worked for 15 years prior to his retirement.

“We hope that the Trust will now develop the necessary action plan taking on board the recommendations from the serious investigation report and the report prepared by Professor Packam, Associate Medical Director of Nottinghamshire Healthcare NHS Trust.”

We can help you to claim compensation for clinical negligence if a serious injury or fatality has occurred as a result of inadequate supervision and care. See our Mental Health Negligence Compensation page for more information.