Coroner criticises mental health trust after patient hanging

Mark Daniels, 56, hanged himself in November last year after he was meant to be admitted to Rivers Crisis House, run by Camden and Islington Foundation Trust, but this admission never took place.

The coroner concluded the trust’s crisis team:

• failed to visit Mr Daniels twice a day despite a plan to do so
• had no record of why twice daily visits were not attempted
• failed to pass his referral to a crisis house promptly
• failed to consider hospital admission despite knowing that Mr Daniels had attempted suicide several times and had told staff “he would kill himself, albeit not immediately”.

The coroner concluded: “I gained the impression of a lack of cohesion and clinical direction.”

Camden and Islington Foundation Trust has previously been criticised in a review of patient deaths.

The review found “deficiencies in assessing, recording or addressing risks” in more than half of the 19 incidents involving patients between November 2013 and May 2014.

A spokesman for Camden and Islington Foundation Trust said: “We send our sincere condolences to Mr Daniels’ family at this very difficult time.

“The trust had had a long relationship with Mr Daniels and had successfully helped him reduce his drug dependency effectively for many years, often in the community and with the help of our crisis houses.  Mr Daniels had worked positively with us and had responded well to the quality of care provided.  Crisis houses offer excellent care and provide an alternative to hospital admission which many people prefer. 

“A Grade 1 investigation into the incident took place and the trust has revised its communication processes and regular sharing of information between crisis houses to minimise any risk of a delay taking place. Our staff were shocked and upset by his death. We will be responding to the coroner’s concerns in due course.”