doc

A MENTAL health trust has been slammed by an assistant coroner after a man took his own life just over one month after taking a ‘significant overdose’.

Robert Cardwell, 36, who used to live in East Lancashire, was found hanged at his home on September 29, last year. A two-day inquest recorded a conclusion of suicide.

Following that hearing Rachel Galloway, the assistant coroner for North and East Lancashire, Preston and South West districts, criticised Lancashire Care NHS Foundation Trust’s handling of Mr Cardwell’s case and said it needed to 'take action' to prevent future deaths.

The inquest had heard that from June 2016, Mr Cardwell was under the care of the home treatment team (HTT) at the trust. Thereafter, he failed to attend a number of appointments offered to him with crisis practitioners and the psychiatrist.

On July 6, 2016, a nurse at the trust contacted Mr Cardwell to find out why he hadn’t attended an appointment that day. He told the nurse he had no petrol, made an allegation that someone had taken all the money from his account and said he wanted another appointment the following day but it would have to be a home visit.

The following day, Mr Cardwell was discharged from the HTT following a multidisciplinary team meeting but information about the reason for his non-attendance had not been passed on before they decided to discharge him.

At the next meeting on August 10, 2016, Mr Cardwell’s case was not discussed despite his request for clarification as to whether he was due an appointment.

The inquest heard on September 16, a message was left with the HTT by Mr Cardwell’s ex-wife seeking assistance but the crisis practitioner did not follow it up. Mr Cardwell or his ex-wife were never contacted by the HTT.

Having been in police custody on September 18 and 22, 2016, Mr Cardwell informed his friend he was ‘very low and in a dark place’.

On September 28 Mr Cardwell’s ex-wife received a video call from him asking if she wanted him dead. He was found dead the following day, the inquest heard.

In a report to prevent future deaths, Ms Galloway said she was concerned about the process by which messages are relayed from service users to the MDT team, and a lack of record keeping during the meetings.

A spokesman from Lancashire Care NHS Foundation Trust said: “This is a really tragic case and our thoughts and sincere condolences are with Robert’s friends and family. We accept the findings of the inquest and the coroner’s notice and have taken action to make quality improvements to prevent similar incidents from happening in the future.

“The process for recording messages has been changed to strengthen communication and information sharing between teams and to ensure that the most up to date notes are accessible during discussions about our patients. The format of the multi-disciplinary meetings has also been changed to ensure consistency and we are now working to explore ways in which technology can strengthen the process even further.”