“During the inquest evidence was heard that: i”

The coroner’s concerns

1. During the inquest evidence was heard that: i. Mr Nixon was not known to mental health services prior to February 2021. ii. Mr Nixon's accompanied him to every appointment he had with the Home Treatment Team. She had never had dealings with the Mental Health Services previously. iii. Mr Nixon had given permission to the Mental Health Services to share information with . On one occasion it was deemed that a doctor could not impart patient information to Mr Nixon's because he wrongly thought he did not have permission from the patient to do so. iv. Mr Nixon's was unaware that he had disclosed "occasional suicidal thoughts" and was therefore unable to assess the risk of Mr Nixon to himself and accordingly did not take any steps to protect him. v. The Care Plan, Escalation Plan, Emergency Plan were not drawn up in writing until after Mr Nixon's death. No paperwork was sent to Mr Nixon (and in turn not seen by his partner) by the Home Treatment Team prior to his death. Mr Nixon's partner was not therefore party to or privy to any risk assessment. vi. A Carer's Assessment was considered but thought not (who was appropriate as it was believed that Mr Nixon's present at all consultations with the Home Treatment Team) was part of what was seen as ''an intelligent and resourceful couple". vii. The Trust has a patient information leaflet describing what support and advice can be given to a carer. There is a Carer Assessment tool available. 2 2. I have concerns with regard to the following: 6 i. The failure to ensure that family members/carers are fully involved from the outset in the risk assessment process and that they have a full comprehension of steps being taken and/or decisions being made. I believe the Trust should take a more proactive approach. ii. There should be criteria to be applied as to who should be considered for a Carer's Assessment at the earliest appointment with the Home Treatment Team. Such criteria should include whether the patient has given permission to share information; whether the patient and/or the carer have been involved with mental health services previously; whether the carer has been/will be present during consultations; the level of understanding of the carer in relation to steps taken and decisions made and whether they need further help. iii. Such criteria may lead to a full carer's assessment. It is noted that there will always be a delay between assessments and the drawing up of care plans etc which will then be sent out to the patient. By establishing an early process of engaging with carers the medical professionals may build in further protective factors for the patient.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2022-0165

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0