Inquest: NHS trust neglected suicidal Romford man

PUBLISHED: 07:00 04 December 2015 | UPDATED: 10:11 04 December 2015

Walthamstow Coroner's Court

Walthamstow Coroner's Court


A suicidal man killed himself after being neglected by the NHS mental health trust he had approached for help.

The coroner’s list of failures by Nelft

– Failure to appropriately document the risk – doctors didn’t complete a risk assessment and didn’t note relevant risk factors

– Poor communication between the HTT and CRT teams after the assessment on April 24 and a failure to comply with trust risk assessment policy

– Failure to fully document and justify the reason for reducing the level of risk from high to medium on April 24

– Failure to appropriately refer Mr Shrimpton back to the CRT

– Failure to provide any care between April 24 and May 6 despite assessment stating he was at a high risk of suicide

– No review of his medication, no assessment of his mental health, and no housing support in accordance with his plan

John Shrimpton, 66, had no contact from doctors at the North East London Foundation Trust (Nelft) in the 12 days leading to his death, despite being highlighted as a high-risk patient weeks earlier.

An inquest heard how the loving father could have been treated if he was being monitored, but there was confusion over which team was responsible for his care.

He had stopped taking his medication when he was hit by a train and killed at Harold Wood station on May 6.

The ex-civil servant, of Pettits Lane North, Romford, had split from his partner and was facing homelessness when he went to his GP on April 14.

Nelft: We are investigating

A spokesman for Nelft NHS Foundation Trust said: “We are truly sorry that whilst he was one of our patients, Mr Shrimpton received care which fell below acceptable standards.

“We are carrying out a thorough investigation and we will put in place improvement actions identified to improve the quality of care we provide.

“However, we appreciate that any improvements in care can be of little comfort to the family of Mr Shrimpton.”

He told doctors he was feeling suicidal but wanted to get better and agreed to try anti-depressants.

On April 24 he saw doctors from the Community Recovery Team (CRT), who said he had a high risk of suicide but failed to complete risk assessment forms.

CRT psychiatric consultant Dr David Hinchcliffe said John should receive reviews of his mental state and his medication and assistance with his housing situation.

He referred John to the Home Treatment Team (HTT), who visited him that day. Their report reduced his risk to “moderate”, writing John felt suicidal but said he “wouldn’t end his life because it was not a nice thing to do”.

They emailed Dr Hinchliffe two days later, on a Sunday, telling him John had been assessed and to read the internal report log.

The HTT considered the email a referral back to the CRT, but giving evidence at Walthamstow Coroner’s Court, Dr Hinchcliffe said there was no suggestion that was the case.

“Nothing in the email suggested they were handing the patient back to me and it wouldn’t be the appropriate way to do it,” he said. “They should have referred him back to our access team.”

John had no more contact from the trust and stopped taking his medication. Dr Hinchcliffe said there was a “very good chance” doctors would have picked up on his intentions had he been monitored, and could have ensured he took it or admitted him.

At the inquest, Dr Darlington Daniel, the associate medical director at Nelft, admitted John’s death had only been flagged as a Serious Incident the day before the inquest started.

Senior coroner Nadia Persaud concluded John’s death was suicide contributed to by neglect.

She said: “There was a gross failure to provide basic medical attention and Mr Shrimpton obviously needed it. He clearly wanted support from the mental health services.”

She said she would write a report to Nelft, which would also be sent to the chief coroner and the CQC.

Speaking to the Recorder, John’s son Graham said the family was pleased with the result of the inquest, but only found out about the neglect when it started.

“We should have had contact before last week,” he said. “They have avoided it all this time, there’s been a lack of communication.”

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