Serious Incident Report Finds Risk Assessment Was Incomplete Resulting In A Care Plan Which Didn’t Meet His Needs Despite Suicidal Ideation

The family of a man who took his own life just days after being seen by a specialist NHS psychiatry service are calling for improvements to be made to mental health services to prevent future tragedies.

Man seeks assistance after mental health deterioration

Tom Sweeting, who was 51, tragically took his own life in August 2021. In the weeks leading up to his death, his mental health had deteriorated significantly. He sought assistance by attending West Middlesex Hospital A&E, where he was assessed and subsequently discharged by the Hounslow Liaison Psychiatry Service.

Once Tom had been discharged, a junior doctor, who had started the job in August 2021, was tasked with undertaking risk related telephone interviews with him and his partner without immediate supervision. A Serious Incident Report later found that the assessment was incomplete, resulting in a care (safety) plan which did not meet Tom’s clinical needs or properly account for his risk to himself.

Partner instructs medical negligence lawyers to help establish answers

His partner Andrea Pavlicic, 44, from Isleworth, instructed specialist medical negligence lawyers at Irwin Mitchell to help support her at the inquest and investigate the care Tom had received in the days leading up to his death.

The Serious Incident Report prepared by West London NHS Trust found that Tom was “suffering from a Moderate to Severe Depressive Episode with suicidal ideation prior to his death”. The investigation found five care delivery problems, concluding that had Tom been provided with the correct level of care, a more intensive care (safety) plan may have been agreed to manage Tom’s risk of suicide. The report, prepared in December 2021, also made six recommendations of how to improve care for future patients:

1. The Hounslow Liaison Psychiatry Service must ensure that task allocation is competency based.
2. All staff at the Hounslow Liaison Psychiatry Service to be reminded that they should gather collateral information from various sources including family and colleagues in the Emergency Department and incorporate this information into their care (safety) plans, as a key to effective risk management is gathering information from multiple sources.
3. The requirement for the Hounslow Liaison Psychiatry Service to ensure that all staff follow their team operational policy and are up to date with their mandatory training on the Mental Health Clinical Risk Policy. Additional training should be provided to staff, and compliance with the policy should be monitored through supervision and audit.
4. The requirement for the Hounslow Liaison Psychiatry Service team to use the Trust’s clinical summary portal and standard templates to improve the standard of risk assessment and documentation. The use of the clinical summary portal//standardised templates should be subject to a regular audit.
5. The Trust should consider making the Mental Health Clinical Risk Policy an annual mandatory training requirement and not a three-yearly one, given its centrality to the provision of safe and effective care.
6. The Hounslow Liaison Service should ensure that all new staff to the team receive a formal local induction.

Inquest concludes missed opportunity to obtain information from family

An inquest into Tom’s death held between 18 and 20 December 2023 concluded that West London NHS Trust had missed the opportunity to obtain collateral information from his worried family. As such, his risk assessment was not revisited and further options of immediate intervention were not considered.

Coroner Lydia Brown also noted that poor communication from the Hounslow Liaison Psychiatry Service to Tom’s GP surgery meant that an intended prescription for antidepressant medication was not provided. She concluded that an opportunity had been missed to provide him with symbolic supportive assistance in the days before his death.

The inquest heard that no letter of discharge was sent at the time Tom was seen by the Hounslow Liaison Psychiatry Service.  It was only generated in response to investigations taking place after Tom’s death.

Coroner issues Prevention of Future Deaths report 

A Prevention of Future Deaths report has now been issued by the coroner, citing a letter of discharge not being sent within 24 hours and the delegation of a vital task to a junior doctor as “matters of concern”. She also reported a “concerning mismatch” of how junior and senior colleagues at the Trust are expected to record their clinical assessments. Additionally, she expressed concern with regards to the fact that there was “no evidence” that regular training audits, as per the Serious Incident Report, had been taking place.

Expert Opinion

“This is a tragic situation which may have been so different had the appropriate action been taken to put in place a more comprehensive plan for Tom’s care. His family have been left devastated and have asked us to investigate the events on their behalf.

“It’s now crucial that the recommendations from the Serious Incident Report, the learnings from the inquest, and the recommended actions in the Prevention of Future Deaths report are implemented as soon as possible to try to prevent any similar incidents from occurring in the future.” Madeline Nugent, Medical Negligence lawyer

Mental health: Woman pays tribute to dad of sons

Tom was a former news cameraman for Sky News, Al Jazeera, and the BBC, and is described by those who were closest to him as a fantastic son, father, friend, and partner. He was well-known in the local community and would make time for everyone he met. His funeral was attended by around 400 people; a testament to the impression he had on all who knew him.

Andrea said: “Tom was a brilliant dad to our sons and partner to me. We had planned to get married, but it was cancelled during Covid lockdowns and we didn’t have the opportunity to re-book before he died. His suit and my wedding dress still hang together in my wardrobe. Our children and I will continue to miss him forever.

“In the weeks leading up to Tom’s death, his mental health was severely deteriorating, and I was very worried about him. Both Tom and I had spoken to several health professionals, including those at the Hounslow Liaison Psychiatry Service, but it felt like nothing was being done to help him.

“I just hope that those involved in mental health care can learn from what happened and make improvements so that this doesn’t happen to any other families in the future.”

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