Man's suicide could have been prevented, coroner rules

A man who took his own life might have been saved if mental health crisis referrals were improved, a coroner said. 

Nigel Hammond, who was suffering from advanced lymphoma, died in Addenbrooke's Hospital, Cambridge, on 14 March 2024, three days after taking his own life in a fall at his Suffolk home.

In a Prevention of Future Deaths report (PFD), senior coroner for Suffolk, Nigel Parsley, said a mental health support team could have got Nigel Hammond help sooner, had they not needed to go through a GP first.

In the PFD report, following an inquest, Mr Parsley said Mr Hammond had become "seriously mentally unwell" in 2018 and was admitted to a mental health unit for three months.

He had found the admission very traumatic and was "terrified" of the thought of being admitted again. Instead he continued to receive "exemplary" mental health care at home but, on 8 March 2024, his mental health declined again and he was taken to his GP.

The following day he tried to end his own life but was prevented by family intervention, the report said.

His family immediately contacted Norfolk and Suffolk Foundation Trust's first response team who told them Mr Hammond had a GP appointment which he should attend.

They were told that, if needed during the weekend prior to the appointment, they would be able to ask for a Mental Health Act assessment through an on-duty authorised mental health professional (AMHP) from the Suffolk County Council-managed emergency duty service team. From this, if thought necessary, it could allow for Mr Hammond to be admitted to hospital.

The family did contact the AMHP team but they did not request an assessment and in the report it stated they believed home treatment would provide better care for him but Nigel Hammond was later taken to Addenbrooke's Hospital after suffering a traumatic brain injury in a fall at his home.

The coroner's report noted the AMHP believed Mr Hammond to be mentally very unwell and in need of immediate support.

The inquest heard such support would be available within a four-hour target time, from the emergency crisis resolution and home treatment team.

But Mr Parsley said the AMHP was unable to make direct referrals to this team as this was normally done through a GP or primary mental health nurse.

However, neither would have been available before 08:00 GMT on 11 March, just more than an hour-and-a-half after Mr Hammond took his own life in the fall.

Mr Parsley said he was "concerned" that the AMHP had not been able to directly refer Mr Hammond to the crisis team, which would have provided additional support, advice and potentially additional treatment, "in all likelihood preventing his death."

The coroner gave the county council, mental health trust and the government a time limit to respond to his report, outlining any actions they might take. 

Chief nurse at the Norfolk and Suffolk NHS Foundation Trust, Anthony Deery, said the trust's investigation had "highlighted that our standard operating procedures for crisis care could be improved as they did not state clearly enough that the authorised mental health professional could refer directly to the crisis team rather than wait for a GP appointment the next day.

“We have reviewed these procedures and are strengthening the way we communicate with partners so that they are aware of how, and when, to refer so that we can make sure every patient, and particularly those in crisis, can access the right care to meet their needs as easily as possible."

A Department of Health and Social Care spokesman said: "It is important that we learn the lessons from every prevention of future deaths report, and we will consider the report carefully before responding in due course.

"We inherited a broken system where people with mental health issues are not getting the support or care they deserve.  This government will ensure we give mental health the same attention as physical health and shift the focus of the NHS out of hospitals and into the community."