Alan Hunter inquest: Grandfather told NHS he was doomed

Alan Hunter took his own life on October 17, 2020, following two years of spiralling depression. He was 72.

An inquest into his death, which concluded on Thursday, heard that during a meeting with his care co-ordinator in the weeks leading up to his death he was recommended the Japanese number puzzle to manage his anxiety.

During the final day of the inquest, the court also heard that just 11 days before his death, he had told co-ordinator Melanie Hayman that he believed he was "doomed".

In the meeting on October 6, the retired glazier spoke of feelings of doom and how he would become overcome by "impulses" to take his own life.

But despite this - and two prior suicide attempts - Mr Hunter's mental health was not assessed, which may have led to an admission to hospital or increased community support.

Experts giving views during the hearing agreed that had this happened, it would have reduced the likelihood of him eventually ending his life.

The court instead heard that Ms Hayman had followed up the meeting by emailing a senior consultant at the trust - but that her email had "lacked any real sense of urgency".

It was revealed the consultant she contacted was on a period of annual leave at the time - and that she had not contacted anyone else.

However, she told the court she did not recall receiving an out-of-office reply.

Mr Hunter had been in contact with mental health services since September 2019, when he was referred by his GP.

He had three spells as an in-patient in mental health hospitals, including a short spell in Northgate in Great Yarmouth - from which he self-discharged - and a two-month period in Hellesdon Hospital.

During his time at Hellesdon, he found that he did see some improvements, but on being discharged in April 2020 found that Covid restrictions hampered his care.

In the months leading up to his death he had two serious incidents of self-harm, one of which required him to undergo plastic surgery.

Yvonne Blake, area coroner, was critical of the care Mr Hunter received from the Norfolk and Suffolk NHS Foundation Trust - but stopped short of making a report to prevent future deaths.

She said: "I find that NSFT's notes were of a poor quality and do not reflect details about his presentation.

"There was no active care plan in place and what there was had been written in April 2020 [six months before his death].

"There was no proper plan in place which with he could use to calm himself and no contact numbers to call anybody in crisis.

"I find there was no named consultant with responsibility for his care and staff were unclear who they should contact with any concerns.

"When he was discharged he was released into a community gripping a Covid lockdown meaning he had no face-to-face contact until August."

Mrs Blake concluded that Mr Hunter, of Thunder Lane, Norwich, had taken his own life after a deterioration in his mental health - but did not record his death as suicide.

Zeyn Thompson-Green, of NSFT (Image: Copyright: Archant 2019)

Zeyn Thompson-Green, a clinical director for NSFT, told the court that since Mr Hunter's death improvements had been made in how the trust cares for people over 65.

Mrs Blake added: "I am satisfied the trust has made efforts to address discrepancies by appointing new staff and extra training for people who look after older people.

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