“Mental Health a) In-patient care at Longreach Hospital Approximately one year before…”

The coroner’s concerns

1) Mental Health a) In-patient care at Longreach Hospital Approximately one year before Sally’s homicide, had been detained under s2 of the MHA and spent 10 days at Longreach. At the time, there had been noted changes in his behaviour to include a belief that he could live without food for 10 years (Breatharianism), disinhibited 2 Information Classification: CONTROLLED behaviour to include sunbathing naked on a driveway (believing he received energy from the sun) and a stated belief that others could hear his thoughts – thought broadcasting – a potential symptom of schizophrenia. was electively mute, fasting and drinking only distilled water. He was assessed on at least three occasions by a consultant psychiatrist, was reviewed by multiple junior medical doctors, seen by mental health nurses and reviewed by the Early Intervention in Psychosis Team. No one saw any evidence of psychosis and it was felt there were no longer grounds in law to detain him. He was discharged without a diagnosis or a plan for future care. At inquest, accepted the medical team never completely got to the bottom of the reason for his presentation. His Responsible Clinician, , referred to a ‘quandary’ in identifying how much of presentation was due to culture or lifestyle and how much was due to his morbid condition. This uncertainty was not reflected in the discharge summary which described as a ‘model patient.’ One of the most striking features of the evidence was the difficulty Sally then encountered in having re-assessed. Indeed, in the year that followed, despite multiple attempts, was not seen again by a doctor from the mental health team. It is noteworthy that did not believe himself to be unwell, there appears to have been an assumption he had capacity and as he did not consent to treatment, that appears to have become an insurmountable barrier to further care. I felt there were a number of points of learning: i) An inaccurate or incomplete discharge summary that did not reflect the element of uncertainty in diagnosis both doctors outlined at inquest; ii) A failure to discuss with Sally or the maternal side of family how he presented, notwithstanding a clear direction following a first ward round to ‘collaborate’ with the family. This seems particularly relevant given Jacob’s mutism which made obtaining a history difficult. It may be of note that there was a difficult family dynamic with an acrimonious separation of parents. father was spoken to and there was a reference in the evidence that a member of the in-patient team felt it was Sally’s mental health that needed consideration. It was not explored at inquest whether one side of the family’s views had been accepted at the expense of the other’s. iii) The absence of a plan detailing the route back for to be seen again if the reason for his bizarre presentation was due to an emerging illness (that worsened) rather than alternative lifestyle choices; iv) A failure to advise Sally, as Nearest Relative, of her statutory right to request assessment under the MHA. This omission has been noted previously in other PSIF/SIRs. You may wish to reflect whether information in this regard can be included on a website or similar if it is not already and whether there is a need for training of staff in this regard. 3 Information Classification: CONTROLLED v) A delay of five months in putting into the RiO records a detailed timeline provided by Sally while was an in-patient. accepted that had he seen it at the time, he would have had further questions for Jacob. vi) A lack of understanding or professional curiosity about drug-taking and the extent to which, if at all, this contributed to presentation. It was accepted by that he had been misled by who had minimised his history in this regard where there was substantial evidence of illicit drug use, including psychotropics. 2) Community Mental Health Team i) There was a delay of one month in responding to a letter requesting advice from a GP. This was said to be due to staff shortages. At inquest it was noted that, 3.5 years later, staff shortages remain. I am aware the ICB has made concerted efforts to recruit. This is a concern that appears to require attention from central government and so this point needs addressing by the Secretary of State. I note this is not the first occasion I have written to the Minister to make her aware of the persisting difficulties in recruiting mental health staff in Cornwall and the Isles of Scilly. ii) A letter requesting advice was treated as a referral (twice.) It was accepted in evidence that there appeared to be confusion on the part of CMHT staff about how to treat a letter from a GP notwithstanding it set out clearly it was a request for advice. iii) Once the letter from the GP was taken as a request for a referral, attempting to contact the patient by telephone. It was known Jacob was electively mute and so it should have been readily apparent he was not going to respond. Policy appears to have been followed without consideration of the clinical circumstances. iv) Discharging a patient’s referral without any clinical judgment. referral was discharged after he did not answer his phone twice (as he wouldn’t, being mute) or respond to an optin letter (that was sent to the wrong address.) The evidence was clear that lacked insight into his condition and steadfastly refused all offers of support. He was not going to ‘opt-in’ voluntarily. What appeared from the evidence to be a blanket policy of discharging patients who fail to respond (because they are unwell and lack insight) will result in those patients most in need of care being wrongly discharged. In my view, there needs to be some form of triage or clinical attention given to why a patient has not responded and whether it is appropriate to discharge. I recognise that this consideration, in addition to informing Nearest Relatives of their right to request a MHAA, will result in additional burdens for what is an

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judiciary.uk, Prevention of Future Deaths reports, 2024-0267

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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