Concerns raised after Essex man died after being discharged without mental health review
Nicholas Gray died following a history of suicidal thoughts and depression.
A 63-year-old man with severe mental health issues died a week after being discharged from hospital without a psychiatric review or recommended mental health risk assessment, a report has said.
Nicholas Gray died at home in Braintree on July 24, 2023, following a history of suicidal thoughts and depression, exacerbated by pain from a chronic spinal condition.
Mr Gray was receiving pain management and started antidepressant treatment on June 12, 2023.
He made attempts to end his life on June 18, 2023, and was seen by paramedics and the primary mental health team at the time.
While en route to the hospital, Mr Gray wished to go home, but concerns were raised about an underlying cardiac issue he had.
Advice from experts while he was being treated in hospital was that Mr Gray was mentally well enough to go home.
But no plan was put in place for the assessment of Mr Gray’s mental health or risk to himself after he had been discharged.
On June 22, 2023, Mr Gray informed district nurses that he was going to end his life. This was escalated to his GP, who contacted the mental health crisis team.
A day later, on June 23, it was found that Mr Gray had attempted to commit suicide and district nurses asked the acute trust nurse to have a mental health assessment prior to any discharge.
However, Mr Gray was reviewed by mental health services on June 24 with no further action taken.
Mr Gray was not referred to the psychiatrist during his three-week admission in hospital and not reviewed by mental health services prior to discharge.
Mr Gray received treatment for his physical healthcare and alcohol withdrawal and was then discharged on July 17, 2023.
He died a week later on July 24 from an overdose.
The Essex coroner, Sonia Hayes, has raised a number of concerns, including that the trust’s own report, completed after Mr Gray died, which she said contained inaccurate information, including the dates of contacts between Mr Gray and Essex Partnership University NHS Foundation Trust (EPUT) and the details of the interactions.
It said self-harm was noted as “not known or recorded” and there was no record of the mental health liaison nurse reviews on June 24, 2023 or his discharge from EPUT.
Ms Hayes said: “The information used to inform a potential investigation requirement contained significant omissions and was not consistent with the information known to the trust.”
Paul Scott, chief executive officer at EPUT said: “My thoughts are with Nicholas’ family and friends at this very sad time and I send my deepest condolences, both personally and on behalf of EPUT.”