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Father’s concern over mental health services after son dies from stab wound

PUBLISHED: 18:39 14 December 2018 | UPDATED: 18:52 14 December 2018

King's Lynn Magistrates' Court, The Court House, College Lane, King's Lynn. Picture: Ian Burt.

King's Lynn Magistrates' Court, The Court House, College Lane, King's Lynn. Picture: Ian Burt.

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A father has raised concerns about mental health services in West Norfolk after one of his sons died from a self-inflicted stab wound.

A resumed inquest into the death of David Pool, of Swaffham, heard he had been sectioned and was treated at King’s Lynn’s Fermoy Unit early this year.

The hearing at King’s Lynn Coroner’s Court on Friday (December 14) was only for Norfolk assistant coroner Johanna Thompson to give her conclusion following the consideration of a “considerable amount” of evidence.

She said: “Mr [Robert] Pool has described his concerns with the lack of follow-up care after David was discharged from the Fermoy Unit.

“In particular he commented that it was over a month before there was any word from the community mental health team.

“His further concern was because David had told the team that he did not want any further help, he was removed from their list. He said if the family had been asked about this they would have raised concern.”

She added: “Mr Pool believes that if the family had been consulted more, the medical practitioners looking after David may have had more of an understanding of his illness.”

David was discharged on March 27. He seemed to improve initially and he was looking for work. However, he began to become withdrawn again about a week before his death on May 31.

Mr Pool found his son lying in the garden shed of the family home in Iceni Drive. A knife had been used to stab himself in the neck.

The cause of death was hypovolemic shock due to an acute haemorrhage caused by lacerations.

In a statement from David’s GP, the inquest heard that the death came as a “complete shock to all concerned”.

The crisis resolution home treatment team said it noted David’s improvement on April 1 and he had said he didn’t have any thoughts of suicide and was taking his prescribed medication.

And a mental health practitioner said David remained “adamant” after she rang on May 10 to query him saying he no longer wanted to use the service.

The inquest heard that a “serious incident requiring investigation” by Norfolk and Suffolk NHS Foundation Trust had made recommendations to:

• Improve practice on recording of historical risks

• Ensure risk assessments and crisis plans were updated at the point of discharge from the inpatient ward

• Ensure family involvement when service users are discharged from the service

Giving a narrative conclusion, Ms Thompson said: “In answering the question of how, when and why David came by his death I have to consider what we knew about David’s state of mind at that particular point of time.

“A finding of suicide depends on there being an action as well as a state of mind which would mean the person intended to take their own life.

“I cannot find that in relation to David because quite clearly we don’t know what was on his mind at that precise moment.”

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