Coroner calls for re-examination of Danny Sweet’s treatment while under care of Cornwall Partnership NHS Foundation Trust

A mentally ill man who was “passed from pillar to post” by mental health services took a fatal overdose, a coroner has ruled.

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.

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

At an inquest held last Thursday at Truro Coroner’s Court, coroner Andrew Cox stopped short of ruling Danny’s death suicide because he could not be sure he intended to die, but said there were clear issues with continuity of care between the mental health teams charged with his care.

Following Danny’s death, a Serious Incident investigation was undertaken by the Trust which returned several recommendations, including an audit of the Home Treatment Team (HTT) and the Integrated Community Mental Health Team (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 after hearing from Danny’s widow about difficulties she encountered in contacting the service for urgent help.

But the inquest heard that the two main clinicians responsible for Danny’s care were not involved in the completion of the investigation, something the coroner raised in his conclusions. Mr Cox will use Regulation 28 of the Coroner’s Rules to call for Danny’s care to be re-examined to ensure future deaths can be prevented. 

Janet said: “Danny’s death has left me and his children with so many questions, including whether better continuity and regularity of care would have made a difference instead of him being passed from pillar to post without the various teams and departments communicating with each other.

“We had many questions about the mental health service provision in Cornwall and following today’s findings we hope changes are swiftly made to ensure no one else in crisis slips through the cracks.”

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 doctor to consider admission to hospital before finally determining that he was well enough to remain at home under the Home Treatment Team only for him to then be discharged from all services.

Mr Cox said it appeared that no one took a step back to examine Danny’s care as a whole, and no one could explain the conflicting decisions about his care.

Expert Opinion

“Janet and her children are desperate to ensure no one else slips through the gaps in the mental health system in the way Danny did.

“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.

“Danny’s family is grateful to the coroner for using the powers available to him under the Coroner’s Rules to request a Regulation 28 report which hopefully will help to prevent future deaths.

“We will await the outcome of that report and advise Janet on next steps.” Chelsea Parkin - Solicitor

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.