Danny Sweet was discharged from all mental health services under Cornwall Partnership NHS Foundation Trust just days before he died

A coroner presiding over the inquest into the death of a man who took a fatal overdose just days after being discharged from mental health services has called for the NHS Trust involved to re-examine his care so that lessons can be learned.

Danny Sweet died at Royal Cornwall Hospital (formerly Treliske Hospital) in Truro after suffering liver failure brought on by a paracetamol overdose in October last year.

Danny’s widow, Janet, from St Austell, Cornwall, instructed expert medical negligence lawyers Irwin Mitchell to investigate her concerns that Danny slipped through the cracks due to lack of communication between services under the Trust, between September 15 and his death on October 24, 2015 - four days after his 63rd birthday.

At the inquest, held last month, Andrew Cox, assistant coroner for Cornwall and the Isle of Scilly stopped short of ruling the 63-year-old’s death a suicide, telling the hearing that he could not be sure of Danny’s intent.

However, Mr Cox, said he “was concerned” that the very day after a consultant psychiatrist at the Trust contemplated informal admission to hospital, a nurse from the Home Treatment Team (HTT) felt able to refer Danny to the Community Mental Health Team (ICMHT) where he was not seen for a month.

Mr Cox has now used Regulation 28 of the Coroner’s Rules to call for Danny’s care to be re-examined to ensure future deaths can be prevented. This means Cornwall Partnership NHS Foundation Trust has until tomorrow (September 23) to respond to the coroner’s report explaining how they plan to learn lessons to prevent similar deaths in future.

Chelsea Parkin, an expert medical negligence lawyer at Irwin Mitchell, representing Janet, said: “The Coroner’s report is very encouraging, in that it now forces the NHS Trust to re-examine it’s procedures and respond so that other deaths may be prevented in future.

“Because of the nature of his illness, Danny would often give medical staff conflicting information about his mental health, but what his care lacked was someone stepping back and looking at his care as a whole.
“We continue to support Janet and her family in the wake of Danny’s inquest and as the family awaits the response from Cornwall Partnership NHS Foundation Trust.”

Danny suffered from mental health problems for 19 years following a diagnosis of an inner ear problem which required surgery. This rendered him unable to work and impacted on his previously active lifestyle.

The inquest heard that clinicians dealing with Danny would often get contradictory information from him, leading one to consider informal residential mental health support but determining that he was well enough to remain at home before then being discharged from all services.

In the Reg 28 report, the coroner says he wondered whether it may be appropriate to reflect on how to deal with patients who present in an inconsistent manner. In particular, the report questioned “whether it was appropriate simply to presume the best case scenario.”

The report said: “Mr Sweet’s case raises a more general issue namely, how the Trust deals with patients (within the confines of the law as currently drawn) who appear to have capacity and yet decline treatment/care even where family/friends who try to bring to attention the patient’s deteriorating condition.”

Following Danny’s death, a Serious Incident investigation was undertaken by the Trust which returned several recommendations, including an audit of the HTT and ICMHT to ensure protocols are robust enough to support continuity of care for the patients moving between the services.

The report also recommended a survey of patients and families to see how they rate contacting mental health services by telephone.

But in the Reg 28 report, the coroner said the investigation was incomplete in that neither the doctor whom referred Danny to the HTT, nor the clinician who discharged him had any input into its creation.

In his report, addressed to the Trust, Mr Cox said: “You may feel there would be merit in getting the respective clinicians from the relevant departments – hospital liaison, HTT and ICMT – together to see if there are any lessons to be learned.”

Welcoming the report, Janet said: “Danny’s children and I still have so many questions, including whether better continuity and regularity of care would have made a difference. Could he have lived if things were done differently?

“While we have accepted that we may never have those answers, we’re pleased that the coroner has seen fit to carry out a Regulation 28 report which may prevent future deaths.

“We hope that the outcome of that report will save other families from the loss we feel with Danny gone.”

Read more about Irwin Mitchell's work on medical negligence cases here.