Missed Opportunities to Carry Out an Assessment During Mental Health Crisis

Megan Crowther represented the family of a young man who died after he jumped from the Wearmouth Bridge in Sunderland, whilst suffering an exacerbation of Schizoaffective Disorder. The Deceased had been recently been detained under the Mental Health Act for treatment and was discharged from hospital, around two months before his death, under a Community Treatment Order which allowed for him to be detained again under the Mental Health Act if he required further treatment.

The Inquest heard evidence that the Deceased had revealed an attempt to take his own life around two weeks before his death and as a result, the community treatment team were planning more regular checks on the Deceased. Unfortunately, over the following weekend, the Deceased called the Crisis Team in extreme distress and requested he be admitted to hospital. The Deceased was categorised as ‘very urgent’ for which a face to face assessment was expected within four hours. That did not take place. The Deceased phoned the Crisis Team several times over the following two days and repeated that he had plans to end his life, leading to a statement in his final phone call that he would jump from the bridge unless he was transferred to hospital or new accommodation. The Deceased was known to hear voices, specifically in his accommodation. Unfortunately, the Deceased jumped from the bridge within twenty minutes of the final phone call. There was no assessment of the Deceased in the 48 hours between his first phone call and his sad death.

The Coroner found that there were missed opportunities by the Crisis Team to carry out an earlier assessment of the Deceased, and that an assessment should have been carried out before he died. The Court heard evidence that if the Crisis Team had determined that the Deceased could not be managed in the community at this time, then the Responsible Clinician would have detained the Deceased under the MHA for further treatment. There was also a missed opportunity to call the police when the Deceased made a specific threat to jump from the bridge.

Megan Crowther practices clinical negligence, personal injury and inquests. She regularly represents interested persons in a wide range of inquests including complex medical matters and Article 2 inquests.