A narratvie verdict has been recorded at the inquest of a Retford man who hanged himself at his home.
Alvan Brown, 65, had a history of depression and was let down by a series of errors by Notts NHS Trust, who run Bridgegate surgery, Let’s Talk Wellbeing and Mental Health Services for Older People who were responsible for his care.
The inquest, before HM Coroner for Notts, Mrs Jane Gillespie, heard that there was a delay of five days in an urgent referral, which was made by Mr Brown’s GP, being passed to the correct department at Bassetlaw Hospital so that when a call was finally made to arrange for Mr Brown to see a specialist, it was too late .
An urgent referral had been drafted to a specialist mental health team, but there was an unexplained delay of a day in drafting and faxing it to the correct team;
The urgent referral was then faxed to the wrong number;
When it did finally reach the hospital it was left in a pile of routine referrals as there was no system in place to separate urgent matters.
The inquest also heard steps were being taken to improve communications between Trust services following Mr Brown’s death.
Mr Brown’s son Tim said afterwards : “It seems absolutely unacceptable that in 2014 we are discussing the wrong fax number being one of the reasons for my father’s urgent referral not being acted upon.”
“We believe my father and my family were badly let down because of poor process and bad judgement by all the healthcare professionals involved.”
“We tried on numerous occasions to warn the GP about the severity of his depression but none of our concerns were ever acted upon.”
In a statement, Notts Healthcare said: “Nottinghamshire Healthcare offers its sincere sympathies to the family and friends of Mr Brown.”
“We agree that on two occasions communication between services could have been better, but accept that this may not have affected the sad outcome for Mr Brown.”
“We welcome the Coroner’s comments about the steps we have already taken to improve systems that would have flagged up Mr Brown’s contact with more than one of our services.”
“Dr Chris Packham, associate medical director for the Trust, gave extensive evidence about the improvements we have implemented and will continue to develop on improving this aspect of our care.”
“This will be of small comfort to Mr Brown’s family but will improve communications in the future.”