Service Reconfiguration

15.01.19

Risk of further deaths at mental health service warns coroner in wake of 22-year-old death

A coroner’s report into the death of a 22-year-old has slammed a mental health service for children and young adults and warned that there is a risk that future deaths will occur unless action is taken.

Assistant coroner for Birmingham and Solihull James Bennett this week issued a prevention of future deaths report following the death of Daniel Collins, who took his own life in April 2018.

Collins had been treated by Forward Thinking Birmingham (FTB) crisis team, a mental health service led by Birmingham Women’s and Children’s Hospital FT. After a FTB nurse visited him at his home, she discharged him to a counselling service, Living Well Consortium (LWC).

But they left him to contact the service himself, which Collins never did, and there was no follow up from the FTB crisis team generally or to check whether he had contacted the consortium.

Bennett said that during the course of an inquest, evidence revealed matters giving rise to concern and stated “in my opinion there is a risk that future deaths will occur unless action is taken,” adding that it was therefore his statutory duty to contact FTB and the NHS trust behind it, and the Birmingham and Solihull CCG.

The coroner was critical of the transfer of mental health care for Collins from one mental health service to a second service, and of the decision to place the responsibility to make contact on the patient only 72 hours after attempting to take his own life.

The rational was “it is part of their recovery, empowers them and gives them choices,” but there was system in place to require the FTB crisis team to follow up or notify LWC.

“Therefore, patients are at risk of being lost to the mental health service whilst in crisis/only recently out of crisis,” wrote Bennett.

Directed at the CCG and trust, he added that “in my opinion action should be taken to prevent future deaths and I believe you have power to take such action.”

FTB was hit with an ‘inadequate’ rating by the CQC last year, and in April 2017 a coroner investigation into the life of another young person, Leah Abby Ratheram, found “no co-ordination of care at a time of crisis” between FTB and other mental health services.

CCG interim chief nurse Martin Fahy said the commissioner would be monitoring changes made in the service following Mr Collins’ death.

Image credit -  Lynne Cameron/PA Wire/PA Images

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