“as follows”

The coroner’s concerns

as follows. – 1. In late 2018 Nigel became seriously mentally unwell and was admitted to a Mental Health Unit, under the Mental Health Act provisions, for a period of 3 months. Whilst admitted, Nigel was diagnosed with advanced lymphoma (a lymphatic cancer) and upon discharge from the Mental Health Unit spent a further 3 months in hospital being treated for this. 2. Nigel found his Mental Health Unit admission very traumatic and was described as ‘terrified’ of the thought of ever being admitted again. 3. Upon his release, his family, carers, Mental Health Home Treatment team, worked together to provide exemplary care for Nigel, whose health stabilised and in 2020 his care was transferred back to his own General Practitioner. 4. Nigel remained well until Friday 8th March 2024, when due to his decline in mental health he was taken to see his GP, and on the 9th March 2024 Nigel was prevented by family intervention from ending his life by . 5. This incident led to Nigel’s family speaking to the on duty Authorised Mental Health Professional (AMHP) from the Suffolk Emergency Duty Service Team, on the evening of 9th March 2024. An AMHP is a mental health professional approved by a local social services authority to coordinate the mental health assessment and admission to hospital, of individuals requiring admission under the Mental Health Act provisions 6. In evidence, the court heard that the AMHP, in line with Nigel’s family and his own wishes, agreed that an admission to hospital would not be in Nigel’s best interest. The AMHP identified that the successful home treatment regime previously in place would be the ideal care package for Nigel. This arrangement would also be consistent with the ‘least restrictive principle’ which surrounds the application of Mental Health legislation. 7. That said, although Nigel did not meet the criteria for immediate admission, the AMHP believed Nigel was mentally very unwell, and in need of immediate support. The court heard that such support would be available within a 4-hour target time, from the emergency Crisis Resolution and Home Treatment Team. 8. However, the court was told that an AMHP, despite their role in the coordination of the mental health assessment and admission to hospital of a patient, were not permitted to make direct referrals to the emergency Crisis Resolution and Home Treatment Team. 9. The court heard that the normal route for such referrals was via the GP Surgery, or primary care Mental Health Nurse, neither of whom in Nigel’s case would have been available before 08:00 on Monday 11th March 2024. Nigel’s fall which led to his death, occurred at 06:25 that morning. 10. I am concerned, as had the AHMP in Nigel’s case been able to directly refer him to the Crisis Resolution and Home Treatment Team on the 9 th March 2024, mental health professionals would have attended, and been able to provide additional support, advice and potentially additional treatment for Nigel, in all likelihood preventing his death.

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, 2024-0537

Added to Minute Book

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