Family Of Man Found Hanged After Mental Health Phone Assessment Welcomes Report To Prevent Future Deaths

Oliver Ford Hanged Himself In Woodland Near His Childhood Home


Hayley Court, Press Officer | 0114 274 4255

The family of a man who killed himself two days after a telephone assessment by a mental health nurse say they still have questions following an inquest into his death.

Oliver Ford, from Weston-Super-Mare, was found dead on Sunday, August 16, 2015; two days after his mother referred him to Avon and Wiltshire Mental health Partnership Trust.


Oliver’s mother Sarah Ford, and his partner Naomi Marrett instructed expert civil liberties lawyers at Irwin Mitchell after Oliver’s death, believing his life could have been saved if Avon and Wiltshire Mental Health Partnership Trust had taken their concerns more seriously, following a distressed telephone call from his mother.

Senior coroner Maria Voisin today told the inquest, sitting at Avon Coroners Court in Flax Bourton, that she will use her powers under Regulation 28 of the Coroner’s Rules to call for Oliver’s care to be re-examined to ensure future deaths can be prevented. 

The coroner will write to Avon and Wiltshire Mental Health Partnership NHS Trust seeking answers to whether the telephone triaging process should include a risk assessment and that any risk assessment should be documented on the electronic patient record, as well as whether there should be weekend cover for the Primary Care and Liaison Service.

The inquest heard that the mental health nurse who triaged a call from Oliver’s mother on the Friday before his death, was relying on an absence of concern from police and paramedics, to inform her decision-making.

But at the time the officer and paramedic spoke to the call-handler, they hadn’t yet carried out their own assessments of Oliver’s wellbeing and there was an insufficient recording of the information she had gathered.

Ms Voisin said that although it was clear to her that Oliver took his own life, she could not be sure of his intention.

The court heard that Oliver’s mother, Sarah, had asked mental health professionals at the Trust “if my son ends up dead, are you going to take responsibility?” when she called them on Friday, August 14, 2015 in relation to concerns she held about her son‘s mental health who was suffering from paranoid delusions of people trying to break into his home in Weston-Super-Mare.

The inquest heard that Sarah also called police and did not feel that the clinician took her concerns seriously. The mental health nurse she spoke to carried out a telephone assessment of Oliver finding him “calm and polite” according to practitioner notes submitted to the coroner.

The following afternoon, Saturday, Sarah received a text message from Naomi who said that she had received a message from Oliver asking if he could speak to his daughter to say goodbye. The court heard that Sarah immediately tried to ring Oliver but he did not answer. She reported him missing to police and at 2pm the next day, Sunday, 16 August, his body was found hanging in woodland.

The court heart that between February 2010 and November 2013 he had 13 referrals to mental health services, largely following suicide attempts, the latest of which required intensive care treatment.


Expert Opinion
“Nothing can turn back the clock and return Oliver to his children and family, but the family hope lessons have been learned by the Avon and Wiltshire Mental Health Partnership NHS Trust so that no other family has to live with the pain of losing a loved one in these circumstances.

“The family would however like to thank the paramedics and police officers who attended Oliver on Friday 14 August.

“We will now examine the coroner’s findings and advise the family on the next steps available to them.”
Fiona McGhie, Associate

Sometimes mental health professionals can fail in the duty of care. If you or a loved one has suffered due to professional or medical negligence we can help you to claim compensation. Visit our Mental Health Negligence Claims page for more information.