Chances missed to save Stephen
A coroner investigating a man's suicide has slammed mental health services for a catalogue of errors and missed opportunities to offer him treatment.
Claire Hammond has written to the chief executive of Lancashire Care NHS Foundation Trust, claiming there is a “risk that future deaths will occur unless action is taken.” Her warning has been backed by the family of Stephen McDermott, from Leyland, who died after a lengthy battle against mental health problems.
It also comes after concern was raised over Lancashire’s soaring suicide rates, with Preston named the suicide hotspot of England.
In the four months prior to his death, Mr McDermott attended A&E on three occasions having overdosed on drugs and alcohol, and was twice removed from train tracks.
His mother, Audrey McDermott, said: “We certainly don’t feel that Stephen received the treatment he should have.”
In her report to Lancashire Care, Claire Hammond, coroner for Preston and West Lancashire, highlighted the following issues:
l mental health liaison nurses failed to act on five occasions after the 32-year-old turned up to A&E at Chorley Hospital following attempts to end his life;
l the 32-year-old’s problems were blamed on substance abuse ‘without any consideration or assessment of whether mental health issues might be the underlying cause’;
l medical records following one overdose were not properly checked, which led to a nurse assessing Mr McDermott being ‘unaware’ he was found drunk close to a railway station after telling police he was thinking about jumping in front of a train;
l there was poor training and record keeping, and a ‘clunky’ electronic records with different services holding different records;
l there was no mention of a telephone call from Mr McDermott’s GP - described as a ‘trigger point of which he ought to have been referred into services’ — in a review into his care.
Just weeks before Mr McDermott took his own life, his mother contacted the Single Point of Access Team (SPOA) to request a mental health assessment, so concerned was she about his deteriorating state of mind.
No referral was made for follow-up with mental health services, and two weeks later Mrs McDermott contacted SPOA again to advise that her son was in crisis, at risk of suicide and had written a suicide note.
Miss Hammond wrote: “Although a face-to-face appointment was organised for him in eight days time, it was subsequently cancelled, and when Mr McDermott turned up for it, he was turned away without being seen.”
The only time he saw someone face-to-face was at hospital, with other contact by telephone. Mr McDermott’s body was found at his home by his mum on May 25, 2015, where he had died sometime earlier after hanging himself.
At his inquest, Lancashire Care faced a number of criticisms from an independent witness, a consultant psychiatrist, and said there had been ‘missed opportunities’ to offer him treatment.
Miss Hammond added: “Although I did not conclude that these issues caused or contributed to the death, it is my opinion that their existence means there is a risk that future deaths will occur unless action is taken.”
A spokesman from Lancashire Care NHS Foundation Trust said: “The Trust acknowledged and accepted the findings of the inquest, and whilst the Coroner did not find that our services contributed to the tragic death of Mr McDermott they did identify important opportunities to improve our services to minimise risk in future.
“We have developed an improvement plan to address each finding, and this plan supports work already underway such as the replacement of our electronic patient record system, the improvement of partnership working with substance misuse service and work to improve record keeping. Our thoughts and sympathy remain with the family of Mr McDermott.”
The family is now awaiting a report from Lancashire Care detailing what lessons have been learned from Mr McDermott’s treatment.