“Evidence received from the police officers accompanying Mr”

The coroner’s concerns

Evidence received from the police officers accompanying Mr. EVANS during his attendance at Frimley Park Hospital provided that: a. Mr. EVANS presented with a large fresh cut on his arm and also cuts on his Ryan John EVANS (26975-2018) legs which were identified by him as being from self-harm with hospital staff noting that the larger mark on the arm might require stitching. b. Police officers stated that Mr. EVANS was open with hospital staff about his feelings of self-harm depression, and thoughts of ending his own life. Officers further recalled that hospital staff noticed and commented on the self-harm marks on Mr. EVANS’ arms, including whilst staff were dressing a recent selfharm wound on Mr. EVANS’ left arm. c. Officers also recalled Mr. EVANS commenting when offered food by hospital staff that he would rather starve to death. d. One of the accompanying police officers expressed surprise at the fact that Mr. EVANS was not subject to a mental health referral or assessment, in the context of him commenting to multiple hospital staff members about his self-harm actions and ideation. An emergency department consultant at Frimley Park gave evidence which suggested that no mental health assessment was or would have been necessary where Ryan’s presenting complaint was recorded as chest pains rather than of selfharm and/or suicidal ideation. Although self-harm had been noted in the records, no explanation could be provided for why Ryan’s suicidal ideation had not been recorded. The consultant was further questioned in relation to the 2006 NICE Guidelines “Self-Harm: The short term physical and psychological management and secondary prevention of self-harm in primary and secondary care” which are national guidelines that ought to feed into practice at the hospital. These guidelines provide that “Following triage patients who have self-harmed should receive the requisite treatment for their physical condition, undergo risk and full psychosocial needs assessment and mental state examination, and referral for further treatment and care as necessary” and “All people who have self harmed should be offered an assessment of needs, which should be comprehensive and include evaluation of the social, psychological and motivational factors specific to the act of self-harm, current suicidal intent and hopelessness, as well as a full mental health and social needs assessment.” Evidence received during the course of the Inquest was not able to reconcile the contradiction between the NICE guidelines on self-harm and Mr. EVANS having had no mental health assessment despite obvious signs of self-harm and further evidence of disclosure of suicidal ideation. The jury in their Narrative Conclusion found that ‘Despite evidence of self-harm, no mental health assessment was carried out at this point.’ I remain concerned as to how such a situation would be avoided if a patient presented again in similar manner to Mr. EVANS. The additional evidence on PFD matters provided by Frimley Health NHS Foundation Trust does not refer to or address the NICE guidelines on self-harm or explain what would now be done differently were a patient such as Mr. EVANS were to be seen again. The Frimley Health NHS Foundation Trust additional evidence refers to matters being in the process of introduction and new referral criteria with Surrey and Borders Partnership NHS Foundation Trust, but this does not explain how this would prevent the future risk of a patient such as Mr. EVANS leaving the hospital without a mental health assessment. Ryan John EVANS (26975-2018)

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, 2024-0005

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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