Father criticises mental health services following death of Swaffham man

A father has criticised mental health services after one of his sons died from a self-inflicted stab wound.

An inquest into the death of David Pool, of Swaffham, heard that he had been sectioned and was treated at Lynn's Fermoy Unit early this year.

The hearing at Lynn Coroner's Court yesterday was only for Norfolk assistant coroner Johanna Thompson to give her conclusion following the consideration of a "considerable amount" of evidence.

She said David's father, Robert, had voiced concerns about a lack of follow-up care after he was discharged.

She added: "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.

"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 However, he began to become withdrawn again about a week before his death on May 31.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 a pool of blood 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" report 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 on discharge from the inpatient ward and ensure family involvement when service users are discharged from the service

Giving a narrative conclusion, Ms Thompson said she could not rule that David had taken his own life as not be sure that David had intended to do so.

She said: "I cannot find that in relation to David because quite clearly we don't know what was on his mind at that precise moment."