Coroners warn NHS trust over 'missed opportunities' and record-keeping after men die while under care of mental health teams

The nurse had been employed by the NHS at the time of the assault
The nurse had been employed by the NHS at the time of the assault -Credit:Getty Images

Coroners have warned NHS bosses over failings which may have led to two self-inflicted deaths.

In the last week, coroners in Northumberland and South Tyneside have published formal warning notices highlighting concerns that they believe the Cumbria, Northumberland, Tyne and Wear NHS Trust must address to prevent further loss of life.

In once case, Harry Hall died in Hexham while under the care of the the trust's West Northumberland community treatment team. However Mr Hall had not received an in-person assessment in the time between being referred on March 31 2023 and his death - on May 29 that year. He had been due to attend an appointment on May 17 - but this did not go ahead.

Northumberland coroner Andrew Hetherington has written to the trust sharing concerns about record-keeping - suggesting that "crucial information" was missing from Mr Hall's records.

Meanwhile, Leila Benyounes, assistant coroner for South Tyneside and Gateshead, has also raised concerns after the death of Christopher Vickers. Ms Benyounes has also written to South Tyneside Council in order to highlight her fears that there were "multiple missed opportunities" to make safeguarding referrals and prevent Mr Vickers' death.

Coroner Hetherington concluded the inquest into Mr Hall's death on April 30 this year. He found he had died by suicide, and had had a history of depression and mental health illness - and he expressed suicidal ideation in the run-up to his death.

He had seen his GP in relation to his suicidal thoughts on March 28, and was referred to the local 24-hour crisis team at that time. However, when contacted by the "initial response team", clinicians made the decision not to refer him to the crisis team, instead referring him to the community team.

On March 31, Mr Hall was - by letter- offered an appointment on May 17. Then on April 4, he was offered, again by letter, an appointment on June 26.

The coroner, in writing to the NHS trust, said action must be taken. He wrote: "There is nothing in the records, it is unclear if any assessment was undertaken at that time and this is crucial information. It is speculation if the outcome would have been any different if the deceased had been seen prior to his death. I am concerned with regard to the record keeping at this time."

The CNTW NHS Trust has now also been contacted in relation to Mr Vickers' death. After concluding an inquest into his case on February 29, Assistant Coroner Benyounes also issued a formal notice to the trust.

Mr Vickers died on July 18 2021. Mr Vickers had been assessed and treated for mental health conditions and ADHD in both primary and secondary (hospital) care. His local authority had also assessed him as having specific needs.

The coroner found that from the end of 2020 there had been "a worsening of the deceased’s symptoms and behaviours", and that he had reported how the Covid-19 pandemic had exacerbated symptoms such as anxiety and intrusive thoughts. The coroner found how his symptoms had escalated in June 2021 - and that the risk of self-harm or harm to others had increased.

This led to "an increase in referrals and contacts to agencies" by Mr Vickers' family. The coroner heard how he then was triaged and assessed by both the crisis team ad the ADHD team - and then referred to the community treatment team.

Mr Vickers was placed on their waiting list on June 25 - and prescribed medication for anxiety and insomnia.

Assistant Coroner Benyounes added: "Despite the known escalation of behaviours, the increase in the risks to self and to others, and the fact that the Deceased was open to various agencies and services, there were multiple repeated missed opportunities by different organisations to instigate a safeguarding referral for formal safeguarding supervision, or to convene a or multi-disciplinary or multi-agency meeting to co-ordinate the Deceased’s care with the provision of a shared care plan."

In her formal notice to both the NHS Trust and South Tyneside Council, she added: "There were multiple repeated missed opportunities to co-ordinate the Deceased’s care with the convention of multi-disciplinary and multi-agency meetings despite known escalating risk.

"There were multiple repeated missed opportunities to make safeguarding referrals for formal safeguarding supervision from the safeguarding adult public protection team despite known escalating risk to self and to others.

"There remains a risk that future deaths could occur as the missed opportunities were significant and multiple and relate to clear processes and policies that were not followed. Current action that has been undertaken does not address my

Addressing both deaths, Rajesh Nadkarni, executive medical director and deputy chief executive at CNTW, said: “Our thoughts and sympathies are very much with both Harry and Christopher’s family and friends at this difficult time. The Trust takes all patient deaths very seriously, and investigates them rigorously to establish what lessons can be learnt to improve the care we provide."

"In Harry’s case, we will give utmost attention to the coroner’s findings and respond in due course with how we have learnt from the incident and the changes we will make to our services. In Christopher’s case, we have already made several changes based on what we have learnt from this tragic incident."

The trust said that following Mr Vickers' case there had been "a lot of work" to improve staff awareness and skills with regard to domestic violence and safeguarding referrals - and the process that should be followed. They added that "consideration of a multi-agency meeting" was now a standing agenda item for multi-disciplinary teams.

Dr Nadkarni added: "Our domestic abuse policy was updated following Mr Vickers’ death, however, following the inquest, we have decided to review this policy again to ensure that the Trust incorporates all the learning from this inquest, particularly around staff roles and responsibilities in relation to safeguarding referrals. This is due to be completed by July 2024."

He also said that a "significant amount of work" had taken place to improve engagement with families and carers.

A South Tyneside Council spokesperson added: "We would like to express our deepest condolences to Christopher’s family and friends. Changes had already been made at the time of Christopher’s inquest, however we have further re-evaluated our internal policies and procedures in light of the evidence heard and the concerns of the Coroner.

"We recognise that collaborative partnership working is key to effective safeguarding and work has been undertaken to develop and improve multi-agency working with partner agencies that support adults with complex mental health needs, and to ensure that vulnerable individuals receive the appropriate care and support."

The council spokesperson added that the town hall was "in the process" of developing a "multi-agency safeguarding hub" to improve collaborative working to keep adults safe.”