Stephen Jackson
4 Oct 2018 · Coroner Emma Brown · Birmingham and Solihull
The coroner's concerns
1. lack of timely mental health follow-up
“Mr. [name redacted] attended his GP and expressed frustration that following his discharge from hospital on the 23" July 2018. He had not been contacted by the home treatment team and his GP wrote to the Kingstanding and Erdington Home Treatment Team that same day asking them to expedite his appointment, reporting that Mr. [name redacted] continued to have low mood and negative thoughts and merited an urgent appointment”
2. feeling unsupported by mental health professionals
“Mr. [name redacted] wrote a very detailed suicide note within which he refers to feeling unsupported by professionals who did not send him appointments or answers his calls, the context would support this being a reference to mental health professionals.”
3. under-funding of mental health services
“Although evidence at inquest has yet to be heard there is a concern that this case, along with several other cases being investigated by the Birmingham and Solihull Coroners' jurisdiction, future deaths may arise due to under-funding of mental health services.”
4. systemic strain on mental health services
“The strain on the systems of mental health services provided by both Forward Thinking Birmingham and Birmingham and Solihull Mental Health Trust has become apparent to the Birmingham and Solihull Coroners in recent months. Consequently this report to prevent future death is being made in conjunction with reports to prevent future deaths arising from 6 other investigations into deaths between May and August 2018 that demonstrate a risk that future deaths will occur as a result of under-funding. 6”
5. lack of formal communication of concerns
“In addition to this report letters are enclosed from the Medical Directors of both Trusts setting out their concerns.”