Coroner's report released over death of Cromer teenager
PUBLISHED: 10:53 15 June 2019 | UPDATED: 14:50 15 June 2019
A coroner's report into the death of a Cromer teenager has been made public.
Nyall Brown died on May 22 last year, aged 19, and the medical cause of death was given as hanging.
The healthcare organisation responsible for his care came under sharp criticism at the inquest in April.
Mr Brown had been under the care of Norfolk and Suffolk Foundation Trust (NSFT) when he died.
Senior coroner for Norfolk Jacqueline Lake wrote to the chief executive of the trust following the inquest, as she felt changes had to be made to prevent future similar deaths.
In the report, released on Friday, Mrs Lake said: "During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken.
"The matters of concern are that evidence was heard that Mr Brown's care records were not reviewed prior to his being seen, which would enable Mr Brown's full history and risks to be taken into account when assessing him.
"This is a matter which has been raised with the trust previously. Staff are expected to read previous records relating to a service user, but this is not always happening.
"This matter was not considered in the otherwise thorough investigation conducted by the trust."
At the inquest, Mrs Lake warned that the trust was making the same mistake repeatedly, as the teenager's mental health records had not been looked at before he was seen.
Mrs Lake gave a short narrative conclusion at the end of the inquest. She ruled out a conclusion of suicide as she said she could not be sure Mr Brown meant to take his own life.
Diane Hull, chief nurse at NSFT, said: "We are grateful to the coroner for issuing a prevention of future deaths report which will help to ensure that each member of our staff coming into contact with a service user for the first time will review their records in order to have a full history of the care we have already provided."