“1 While acknowledging Daniel’s high level of contact with the IHBTT team, the evidence…”

The coroner’s concerns

5.1 While acknowledging Daniel’s high level of contact with the IHBTT team, the evidence was that no one was taking responsibility for his care in a ‘key worker’ type role. The large number of people seeing Daniel did not make deep professional relationships with him which would allow his needs and risks to be addressed in a person centred and properly risk sensitive way. The relationships with Daniel were superficial and this infected the risk assessment process. The large number of mental health professionals in contact with Daniel inhibited him establishing deep relationships of trust. 5.2 The risk assessments themselves were therefore superficial, often relying uncritically on self-reporting without meaningfully engaging in suicide risk prevention. The initial risk assessment on first contact on 16.07.21 was flawed in that, despite the presenting context being an attempt at suicide by hanging, the risk assessment was ‘low risk of suicide’. 5.3 Daniel was a serving soldier and there was a failure to meaningfully communicate and engage with his Regiment and the medical staff attached to it. 5.4 Communication with the family was superficial and the evidence was that their perception was that they couldn’t fully share issues and concerns because of perceived barriers in information sharing. This may not have been the team’s intention, but it was the reality felt by the family. This inhibited their engagement with the team in Daniel’s best interests. The evidence of was that engagement with the family was important because they were the people who knew Daniel best and who would be the first to identify any risks or concerns. 5.5 There was evidence that staff in the team struggled with decision making around information sharing. For example, on 15.09.21, the day before he died, Daniel’s girlfriend called to share concerns about his wellbeing. The person taking the call indicated that Daniel’s lack of knowledge of her referral placed the team in difficulty in sharing the information. In the event, a practitioner saw Daniel for a visit only a few minutes later and correctly identified his need for an urgent psychiatric review. Notwithstanding this, I considered that this was evidence of a failure to understand the basics of risk-based information sharing. 5.6 In summary, therefore, I considered that there was evidence that a failure to address these issues could create a risk of further deaths: Superficiality of risk assessments Lack of a key worker approach Lack of communication with the armed forces, army in this case Superficiality of communication with the family Anxiety about appropriate risk sharing 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 16.02.23 I, the coroner, may extend the period.

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, 2022-0372

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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