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Care team failed to raise alarm after visiting Romford man on the day he killed himself

PUBLISHED: 17:00 18 March 2020

Goodmayes Hospital in Barley Lane where Nelft is also based. Picture: Ken Mears

Goodmayes Hospital in Barley Lane where Nelft is also based. Picture: Ken Mears

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A coroner has called on Havering’s mental health trust to investigate after a care team failed to raise concerns when visiting a Romford man on the day he took his own life.

On Tuesday, October 1 last year, Lee Carpenter died following an ongoing battle with a mental health disorder.

Coroner Nadia Persaud gave a narrative verdict at Walthamstow Coroner’s Court on February 25, in line with conclusions made about the care provided by staff at Goodmayes Hospital, one of the health centres run by the North East London Foundation Trust (Nelft), where Mr Carpenter was last treated.

On March 3 she filed a report to Nelft which calls on the mental health trust to take action to prevent further deaths.

Prior to his death, Mr Carpenter had been referred to the trust by his GP on August, 2019.

The GP requested an urgent review and had to send a second referral on September 10.

Ms Persaud said: “There was a lack of robust risk assessment, care planning and medication review following the GP referral.

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“Mr Carpenter’s mental state declined considerably from September 24 with numerous risk incidents.

“When he was visited at around 11am on October 1 by the home treatment team there was no response from him. The alarm was not raised by the team at that time.”

Later that afternoon on October 1, Mr Carpenter was found dead in his home by his family.

Despite the GP making an urgent referral to the mental health team on August 6, the referral was triaged for a “non-urgent response”.

“There was no documented rationale for overriding the GP’s request for an urgent review,” said Ms Persaud in the report.

She asked that Nelft respond to the report by April 27.

A spokeswoman for Nelft said: “We would like to express our deepest sympathies to the family and friends of Mr Carpenter.

“We are not able to comment on individual cases but are determined to continuously improve the quality of care we provide to our service users and their families.

“We have taken action following the coroner’s report and continue to undertake the necessary work to improve our services.”


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