Health failings not to blame for suicide of mentally ill engineer

Mind Your Mental Health

Mind Your Mental Health - Credit: Archant

A coroner criticised communication between GPs and the borough’s mental health services at an inquest on Wednesday, but found that those failings were not responsible for a young man’s suicide.

Simon Baxter, 26, of Brackendale Gardens, Upminster, was found dead on November 4 last year, a day after his older brother Anthony had visited their GP seeking medical help dealing with Simon’s deteriorating mental health.

The inquest, at Walthamstow Coroner’s Court heard that an administrative error led to Mr Baxter’s urgent referral as a high-risk patient being incorrectly filed by North East London NHS Foundation Trust’s (Nelft) mental health assessment team.

This mishap meant that instead of being contacted within 24 hours of referral, an assessor phoned six days later, by which time Simon, who had been suffering from paranoia and hallucinations, was already dead.

“I may have been a bit aggressive,” said 32-year-old Anthony when asked about the call he eventually received, “I just said, ‘you’re too late mate, you’re too late’.”


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In her concluding statement, Senior Coroner Nadia Persaud said the handling of the case was a terrible error, but pointed out that more urgent care would not have guaranteed a better result, as Mr Baxter killed himself less than 24 hours after his brother sought help.

She said: “While I think that he was failed by the mental health services in that he should have been contacted more urgently, I don’t think that would have made a difference in the outcome.”

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During the inquest it was revealed that the Haiderian Medical Centre, on Corbets Tey Road, Upminster, used an out-of-date referral form that did not adequately convey the patient as high risk.

However, the coroner was assured by Nelft that new forms would be redistributed to GPs, and was satisfied there had been substantial changes in the borough’s approach to mental health since Mr Baxter’s death.

The coroner ruled that Mr Baxter took his own life while the balance of his mind was disturbed.

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