Leicestershire NHS Trust told to take action, after man found dead days after calling mental health service
An inquest into the death of Christopher Larsen has highlighted failings in the care provided by mental health crisis teams
Last updated 9th Jul 2024
Concerns have been raised of a mental health service for people in Rutland, after a man took his own life a little over a month after being discharged from Leicestershire Partnership NHS Trust care.
Christopher Larsen had been under the care of a crisis team run by Leicestershire Partnership NHS Trust (LPT) shortly before his death.
He was discharged from the service in December 2022. A little over a month later, he was found dead by his wife.
At the time of his discharge from the service, Mr Larsen’s risk level had been incorrectly downgraded to “low risk”, an inquest into his death heard.
A ‘Serious Incident Investigation’ report by LPT into how its teams acted prior his death states it was “unclear why it was felt the risks had subsided by the time of discharge”, because at that point, Mr Larsen still had “ample markers for high risk of suicide”.
He was discharged from the service with “no planned support” other than scheduled counselling
The report also identified several “red flags” relating to Mr Larsen’s well-being which the trust said were “not robustly considered” when assessing his risk.
He was discharged from the service with “no planned support” other than scheduled counselling – but that would not begin until three weeks later, a report by coroner Isobel Thistlethwaite stated.
There were also errors in Mr Larsen’s LPT file, the coroner added.
A LPT team meeting to discuss Mr Larsen’s case detailed a previous suicide attempt, but meeting documents show that it was said he “did not want to do it again”.
Ms Thistlethwaite said this was incorrect, however, as Mr Larsen’s medical records stated he “could not give assurances that he would not try to do this again”.
Because of the error, the LPT team “made decisions based upon incorrect information”, she added. There had also been “several requests made” to the team for Mr Larsen to be reviewed by a medic, but this did not happen, according to Ms Thistlethwaite.
The Serious Incident Investigation report by LPT concluded that it was “unfortunate that he was not reviewed by a medic”.
The nurse who called him acknowledged at the inquest that she had not read Mr Larsen’s medical records
There was “evidence of a severe depressive disorder” months before Mr Larsen’s death, the trust’s report continued. However, “this potential diagnosis was not identified or explored”.
Mr Larsen contacted the crisis team again two days before his death to report the return of suicidal thoughts.
He requested medication, counselling and mental health support.
The crisis team called him back the next evening to carry out a “safe and well call” and arrange a triage appointment.
However, the nurse who called him acknowledged at the inquest that she had not read Mr Larsen’s medical records nor his referral document before making the call, and “therefore she was not aware of the risks relating to Mr Larsen”.
He was found dead the next day.
Following the inquest, Ms Thistlethwaite told LPT it needed to learn from Mr Larsen’s death.
The Trust says they'd like to apologise to Mr Larsen’s family for their loss
She said that while the investigation carried out by LPT into Mr Larsen’s case “did uncover and accept some failings in relation to the care provided to him”, it failed to identify “all the matters arising at inquest”.
She added that some of the matters LPT had uncovered had not been included in its action plan for improvement.
The coroner also had “concerns about the implementation and embedding of the lessons learned”, saying: “In this case, the live witnesses who gave evidence during the course of the inquest did not demonstrate that learning had filtered down to the front-line staff.”
She concluded: “I am therefore concerned that the Serious Incident Investigation process at LPT does not support a robust and critical analysis and investigation of the care provided to patients.
Further, I have concerns about the ability of the trust to embed changes and learning.
“This failure to properly explore matters and learn where possible inevitably leads to a delay, or failure altogether, to learn lessons which are vital to patient safety across the whole trust.” Ms Thistlethwaite issued a Regulation 28 notice against the trust, calling on it to make changes.
A spokesperson for LPT told the LDRS: “We would like to apologise to Mr Larsen’s family for their loss. We take Regulation 28 notices very seriously, and as a learning organisation we look to use these to improve our services where possible.”
If you, or someone you know, is struggling with their mental health, you can access local mental health services and national helplines via the NHS website, or call 111 if you're in need of urgent help.