A South London Coroner has called for a lifesaving ‘red flag’ system after a man killed himself, having visited six different hospitals nine times in a month. Patrick Soames, 24, took his own life after a string of hospital visits.
Edmund Gritt, Assistant Coroner for South London, has since called on the NHS to implement a “risk flagging” system to help medical staff know a patient’s full staff when they’re in a crisis. Patrick’s at risk status and history hadn’t been made aware to staff, as there is no system in place.
The 24-year-old was found at his home in Coulsdon, South London, back in June 2021. After an inquest into his death was conducted, Mr Gritt learned NHS trusts do not share full medical histories between regions.
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If a patient visits A&E with self-harm injuries, staff won’t know about any previous incidents in other locations. Currently there is no single “global” system which consolidates medical history and is accessible 24 hours a day seven days a week, the hearing heard.
South London Coroners’ Court, Croydon, was told five NHS trusts and three police forces in different areas had contact with Patrick in the final month of his life. However, there was not a joined-up process piecing together Patrick’s repeated visits to the various hospitals.
As a result the Coroner warned Health Secretary Steve Barclay others could die if such a system is not set up. He recommended the NHS and Mr Barclay set up an automatic flagging system, which will be able to notify staff if a person is repeatedly presenting with self-harm injuries and consequently at risk.
Patrick worked and lived at his parents’ house before a “severe emotional deterioration” in the last month of his life, which led to his multiple hospital visits with self-harm injuries, with some incidents also involving police contact.
He’d repeatedly cut himself, overdosed and began drinking excessively, which was out of character, the inquest heard. Patrick had gone missing when he travelled to Yorkshire.
Despite his significant recent history he fell through the cracks as the trusts did not share full medical histories between different regions. Patrick turned down psychiatric liaison services and abruptly terminated a brief psychiatric assessment, having the medical capacity to do so.
The Coroner stated that because he refused care it was vital clinicians had a clear picture of his medical history, but they did not. When Patrick presented at five NHS trusts and three police forces across the country there was no “global focus” cataloguing his behaviour, and clinicians and officers were left to acquire “piecemeal” information of what was happening.
GPs are where the information about contact with other clinical agencies, such as A&E visits, is located and are therefore a contact point for history information. However, the inquest heard it is not possible for A&E staff to get medical history from a GP practice out of hours. Several of Patrick’s A&E visits were out of hours.
A 2020 study published in the Journal of Clinical Psychiatry found people are “significantly” more likely to commit suicide at night. Police told Patrick’s local authority he was at risk following one self-harming incident – the authority passed the information onto an NHS trust in an area Patrick did not live in, and none of the NHS trusts Patrick attended had the information or any means to access it.
Patrick died on June 21, 2021, and an inquest found the medical cause of death was suicide by suspension. Mr Gritt wrote to Steve Barclay and a chief executive of NHS England, Amanda Pritchard, calling for the case to be investigated.
It was also sent to Patrick’s parents, Croydon Health Service NHS Trust, Surrey and Sussex Healthcare NHS Trust, South London and Maudsley NHS Foundation Trust, Surrey and Borders Partnership NHS Foundation Trust, and London Borough of Sutton.
Mr Gritt wrote in the report, published on Tuesday, April 18: “Patrick lived at home with his parents and was employed. However, in the final month of his life, Patrick experienced a severe emotional deterioration. He engaged in repeated episodes of serious self-harm including cutting his arms, medication overdose and uncharacteristic excessive alcohol misuse. At one point, he briefly went missing when he travelled to Yorkshire – where he also self-harmed.
“On nine occasions during that final month, Patrick attended various hospital accident and emergency departments [in different NHS trust areas], following incidents of self-harm. Five NHS trusts and three police forces in different geographic areas had contact with Patrick in the final month of his life and each thereby gained some information about the risk to him. However, that information was by reason of the agencies falling into different geographic areas.
“There was no single effective global focus for the information being acquired piecemeal about Patrick’s pattern of serious self-harming behaviour. The various agencies were significantly impeded in forming a single clear picture of Patrick’s pattern of behaviour which was particularly necessary in circumstances where he was not engaging and therefore not assisting in providing a complete history himself.
“GPs act as a repository for information about contact with other clinical agencies such as attendances at accident and emergency departments and therefore serve as a point of contact for information about past history. However, I heard evidence at inquest from accident and emergency consultants that it is either not possible to access information held by a GP practice out of GP surgery hours or where it is possible to do so that is only available if the GP is in the same geographic area as the accident and emergency department.
“Several of Patrick’s attendances at accident and emergency departments were out of GP surgery hours. Those trusts which did have direct contact with Patrick were never made aware of that piece of information nor had any means of accessing it.
“I heard evidence that there is no national ‘risk flagging’ system: for example, when a person attends an accident and emergency department having self- harmed, the fact of a previous self-harm attendance at a different accident and emergency department is not systematically flagged up.
“In summary, there was no single effective global focus consolidating the information which was flowing into the various agencies about Patrick; no global focus to which those agencies could in turn refer in emergency to obtain the totality of information about Patrick’s recent pattern of behaviour; no national ‘risk flagging’ system to alert those agencies to his significant recent history.
“During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you.”
A JustGiving page was set up after Patrick’s death, in which a friend wrote in tribute: “Everyone who knew Pat knew he was such a kind, intelligent and funny young man.”
The Department of Health and Social Care and NHS England have 56 days to respond to the Coroner’s letter.
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