Coroner slams mental health service

A CORONER has today accused the Suffolk Mental Health Partnership of adopting a “pass the parcel” approach in dealing with a depressed alcoholic who ended up taking his own life.

MENTAL health chiefs today promised changes had been made to its service provision following the deaths of three patients in a year.

Suffolk Mental Health Partnership made the vow in the wake of damning comments made by a coroner who criticised the way Martlesham man David Lyons was dealt with in the weeks leading up to his suicide.

A depressed alcoholic, Mr Lyons, of The Chase, was found hanging in his garage on May 11 last year.

At an inquest into his death last week, coroner Dr Peter Dean accused the partnership of a “pass the parcel” approach in dealing with the 51-year-old and claimed the system required an overhaul.

Mr Lyons' suicide took place only three days before that of Christopher Schonbeck, of Ipswich, who hanged himself with his own belt while a patient at St Clement's Hospital.

On March 9 this year, Anthony Warren, of Kesgrave, who had been receiving mental health support, died after he was hit by a train at Witham.

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Robert Nesbitt, director of community engagement and Suffolk Mental Health Partnership, said reviews after each of the three deaths had led to reforms.

He said: “We always carry out a review if it's a death we were not expecting, and if there are any concerns we carry out a full independent review.

“In relation to My Lyons, who had an alcohol problem, we have looked at how our substance misuse and mental health teams can work closer together. Changes have since been made to improve communication.

“The coroner said Mr Lyons fell through the net. He said he was looking for more joined-up services and that's what the review has sought to tackle.

“We have also reviewed our observation policies and security arrangements to stop people absconding.”

Mr Nesbitt claimed Mr Schonbeck had a “complicated history” and, following his death, said thought had been given to the guidelines surrounding what patients should be removed of.

But he added: “Where do you stop? Do you take their shoe laces? Do you take their bed linen? How far do you go?

“The key to this is the level of observation. He was found rather quickly but not quickly enough.

“We don't try to pretend that we always get it right. Our purpose is to try to prevent suicide, but we are dealing with people who are highly unpredictable.”

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The inquest into the death of David Lyons:

DAVID Lyons was found hanging in his garage by his wife Sharon. An inquest into his death at Endeavour House, Ipswich, concluded that he took his own life.

Coroner Dr Peter Dean said there were lessons to be learnt, after Mr Lyons' case was referred to several departments, with little contact with the actual patient or his family.

Mr Lyons began drinking excessively following the death of his brother Malcolm, and in April 2006 he made a failed attempt to commit suicide after taking an overdose.

On May 5, just six days before his death, he called St Clement's claiming he was going to commit suicide. Mrs Lyons told the inquest that he was due to have a mental health assessment but no one turned up. It was only the day before his death, on May 10, that he was seen by a psychiatrist.

Dr Dean said: “The system is not right and needs changing. It has got to be robust and has got to be safe. It seems astonishing that someone could have slipped through the net like this.”

Mr Lyons' case was dealt with under the new triage system, which has a vetting process to avoid visiting unnecessary referrals. The triage team passed the case on to a Crisis Resolution Team without having seen Mr Lyons, which in turn passed the case to a community psychiatric nurse.

Dr Dean said: “The job of the crisis team is to assess a person in a crisis but how can you do that if you don't speak to them?

“There seems to be a pass the parcel approach. A lot of this was left to chance and clearly that should not happen in the future.

“It seems that everyone was focusing on one side (his alcohol dependency) and not the psychology problem relating to his self harm.”

Christopher Schonbeck and Anthony Warren

CHRISTOPHER Schonbeck, of Finbars Walk, Ipswich, used his belt to commit suicide at St Clement's Hospital on May 14, 2006.

The 40-year-old had asked a staff nurse to kill him just hours before he took his own life.

Robert Nesbitt, director of community engagement and Suffolk Mental Health Partnership, admitted “it would have been better” if the belt had been taken away.

Anthony Warren, of Grange Farm, Kesgrave, was killed at Witham railway station by a train travelling at 100mph on March 9 this year.

After the 43-year-old's death, Suffolk Mental Health Partnership announced it was conducting a review to learn if services could be improved.

Although an inquest has been opened into Mr Warren's death, it has been adjourned while further investigations take place.

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