Crisis team ‘missed opportunity’ to prevent Ipswich couple’s deaths
PUBLISHED: 16:54 17 April 2019 | UPDATED: 11:04 18 April 2019
An Ipswich couple were sent home ‘distressed and hopeless’ by a mental health crisis team hours before their deaths, which may have been prevented with better assessment, a coroner has ruled.
Thomas Kemp, 32, died from self-inflicted stab wounds to the neck, torso and limbs outside the flat he shared with wife, Katherine, 31, who died from stab wounds to the chest, on August 6.
Coroner Jacqueline Devonish said his non-compliance with prescription medicine had also contributed to a likely psychotic episode and “frenzied attack”.
The University of Suffolk course administrator, who had paranoid delusions and serious body dysmorphic ideas, which prompted him to see escorts for reassurance, was found covered in blood in Siloam Place, where police then forced entry to a flat and found his wife with 28 stab wounds, a blood-covered carving knife in a kitchen draw and a bloody steak knife on the floor.
Police had already visited, just before 3am, based on information man was threatening to harm himself, and had taken the couple to the door of the emergency department, where they were referred to a crisis response team, which decided Mr Kemp would not benefit from face-to-face assessment, despite triage nurse Maria Tabar reporting him as high risk over the phone.
Mental health nurse Indardaye Ramroop-Dip answered the call but said she was not told of the risk to Mr Kemp, whose previous notes listed him as not high risk, and who was due to be contacted later that morning after making his own call to the psychiatric liaison service the previous day.
Returning a narrative verdict on the deaths, Mrs Devonish said the police and ambulance service had acted appropriately, but that a hospital receptionist missed an opportunity to share information with the triage nurse, despite Mrs Kemp's obvious distress.
She said plans to call Mr Kemp did not absolve the crisis team at least seeing him before requesting he be discharged by a charge nurse, who described the team as “blasé” about his body issues.
The coroner said the charge nurse also missed an opportunity to challenge the decision to send the couple away “distressed and hopeless”, adding: “In circumstances where there were available options, the failure to even consider these alternatives was a missed opportunity to have done something effective to prevent these deaths.”
Mr Kemp's family said the couple had been “failed” and demanded better systems in the future.
Diane Hull, Chief Nurse of Norfolk and Suffolk NHS Foundation Trust (NSFT), said: “We would like to express our most sincere condolences to the families of Thomas and Katherine Kemp.
“I have personally met with members of Mr and Mrs Kemp's families and have offered my ongoing support. I remain available to meet with them to provide anything they would find helpful.
“NSFT and East Suffolk and North Essex NHS Foundation Trust [ESNEFT] commissioned a review of the care and treatment of Mr Kemp, and the events leading to his death and that of his wife.
“The purpose of investigating an incident thoroughly is to learn lessons. There is an absolute need to learn what went wrong and why, so that services can be improved and, most importantly, prevent another family suffering what Mr and Mrs Kemp's families have been through. Our Trust believes we have a duty to do this for the sake of future service users and their families.
“The review identified areas for improvement, which mostly related to team working, relationships and communications.
“NSFT and ESNEFT have been working on a joint action plan. This encompasses the recommendations made in the review and our Trust is now in the process of implementing all of them across our entire organisation.”
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