Mental health services had 'insufficient resources' to see man who took his own life after waiting five months for assessment
PUBLISHED: 15:21 09 February 2018 | UPDATED: 16:54 09 February 2018
A serious incident review into the death of 32-year-old John Worthington found mental health services had "insufficient resources" to offer him in assessment in less than five months.
Diagnosed with Asperger’s and emotionally unstable personality disorder in October 2016, John was becoming increasingly frustrated with the lack of mental health support in the months leading to his death, an inquest heard on Tuesday.
And by June 6 last year he called NHS 111 four times to seek help. Communication difficulties due to a speech impediment led to him becoming frustrated and aggressive, and call handlers hung up on him.
During the fourth call he made an attempt on his life.
Police and paramedics attended and resuscitated John, from Norwich but he died on August 11 at the Norfolk and Norwich University Hospital.
MORE: Man “frustrated” at mental health delays took his own life after NHS 111 hung up on him
According to the serious incident requiring investigation (SIRI) report from Norfolk and Suffolk Foundation NHS Trust (NSFT), John was offered an assessment “within an acceptable time frame...given the demands on the service at the time of the incident.”
But it accepted there had been a strain on resources, adding a business case has been submitted for additional psychology capacity.
The review found “insufficient psychology resources to meet demand” as the psychology team were “unable to respond within five or 28 days due to insufficient capacity”.
Today, John’s parents have released recordings of his NHS 111 calls to raise awareness of male suicide in a bid to prevent John’s fate happening again.
After a second call handler hangs up on him, during the third call John says: “You are discriminating against a human being that has a problem who is asking for help.
“The last person I spoke to hung up on me while I was trying to get my words out.”
The handler apologises and repeatedly offers an assessment.
John goes on: “I’m done with your service and I’m probably going to try and hurt myself tonight.”
In the final call at 2.53am, John is actively threatening to hurt himself and an ambulance is dispatched.
During the inquest, John’s parents said his death could have been prevented.
His dad Keith Murdoch said: “It seems there was a pattern of escalation in his mental state towards the end.
“If he had got help sooner it might have given him coping strategies to get around how he was feeling. The point of this for us is to stop other families having to go through this.”
At the inquest John’s parents and his GP, Henry Jones from UEA Medical Centre, asked why NSFT had failed to attend.
Two days after being asked for comment by this newspaper, Dr Bohdan Solomka, medical director at NSFT, said: “Our Trust is deeply concerned that his family and Mr Worthington felt that he did not receive the support he needed. We have fully investigated his case, and there are learnings we will take from this.
“We will be looking at the case further with our most senior clinicians as part of our review of any death of a service user under our care. This is to fully test not just whether the care offered was sufficient, but also to understand any learnings or ways in which we can continue to adjust our services to better fit an individual’s needs.”
Dr Solomka said John had been in Trust services for some years and had been receiving support from various teams before he attended A&E in December 2016.
“There he was assessed by a senior mental health nurse, and our Trust had also received a referral that day from his GP.
“Mr Worthington was then seen by a senior community mental health nurse and a clinical nurse specialist on February 17, 2017. After this he was offered an assessment appointment for psychological therapy with two Clinical Psychologists in May 2017, but sadly he did not attend this and a new date had to be set.
“Although no formal care plan was in place as Mr Worthington was still under assessment, he had been given a crisis service telephone number should he feel he was becoming more unwell, as well as having been given a duty worker phone number, and the MIND crisis helpline number.
“The mental health teams working with him had also made referrals to charities for support around managing his debt and to third sector organisations supporting people with Asperger’s.
“There were also a number of contacts by phone with the service user, as well as contact with a psychiatric nurse and a psychiatrist when he attended A&E.”
Patient records not available to NHS 111
We asked NSFT why John’s medical notes were not available to call handlers at NHS 111 and if they had advised him to call the out of hours service.
An NSFT spokesman said: “Our patient’s records are not made available to call handlers, and will only be accessed by an NSFT clinician. However, there are protocols in place whereby other health organisations can call NSFT to ask for advice. Under exceptional and appropriate circumstances, we would provide appropriate information to assist them in dealing with a caller.”
“It was documented that [Mr Worthington] was advised on December 21, 2016 that he could contact NHS 111 if he felt he could not wait to see his GP during normal working hours, in order to trigger a further referral through to CRHT. There was no specific care plan that stated he should call NHS 111.
“But Mr Worthington had also previously been given a crisis service telephone number, as well as having been given a duty worker phone number, and the MIND crisis helpline number.”