The region’s troubled mental health trust has been criticised by Norfolk’s most senior coroner after a man died when he fell from a taxi on the NDR during a psychotic episode.
A week-long inquest into the death of Christopher Sidle heard of a series of “missed opportunities" and "inadequate care” at Norfolk and Suffolk NHS Foundation Trust’s (NSFT).
The 51-year-old, from North Walsham, had been rejected by the Trust’s crisis team on three occasions during the last months of his life - including just three days before he died on July 4 last year.
On the final day of the inquest, senior coroner Jacqueline Lake said she would be issuing two Prevention of Future Deaths (PFD) reports.
"I do accept that the Trust has recognised the concerns in this case," she said.
"I do, however, have continuing concerns. I understand training is being and has been put in place, but the evidence did not reflect that.
"Training clearly needs to go further. I also have ongoing concerns about the knowledge of members of the team’s capabilities – I do think that is something that needs to be addressed.”
Mrs Lake also highlighted that there needed to be further action to ensure emails were picked up promptly and passed to the relevant person.
She will be issuing a separate PFD report to the Department of Health regarding the lack of available beds for mental health patients.
She added: “Although this was not a specific concern with Christopher, it is a concern that I have.
"I do take on board that this is a national problem.
"The Trust has given evidence about the work it has carried out to alleviate this problem and they have clearly again treated this as very serious.”
Concluding the inquest, she recorded a short factual narrative.
She said: “Mr Christopher Sidle threw himself out of a moving taxi and suffered fatal injuries. His state of mind at the time is not revealed by the evidence.
“There were missed opportunities to provide appropriate and timely care to Christopher and assessments carried out in respect of his mental health were inadequate.”
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