Martin Tilley
PFD Report
Historic (No Identified Response)
Ref: 2018-0071
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
No published response · Over 2 years old
Response Status
Responses
0 of 1
56-Day Deadline
11 Aug 2018
Over 2 years old — no identified published response
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner's Concerns
_ Prior to Mr Tilley's last appointment with the psychiatric nurse (CPN) attached to the Homeless Healthcare Team in July 2017 he was talking of self-harm, had suicidal thoughts and was apparently experiencing visual and audilory hallucinations_ It appears that after not attending an appointment with the CPN in July Mr Tilley was no longer seen by the team. Prior to the inquest the Homeless Healthcare Team were asked to explain the circumstances in which such presentation would result in a referral for an emergency assessment by psychiatrist or the tertiary mental health services No answer to this question was forthcoming: Furthermore there was no evidence that Mr was followed up by the Homeless Healthcare Team after July 2017 , Gloucestershire Coroner' $ Court; Corinium Avenue; Barnwood_ Gloucester, GLA 30J Tel 01452 305661 Fax 01452 412618 24"h Drug Tilley Tilley
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action. would like some reassurance as to the processes and guidelines that exist to ensure that vulnerable adults such as Mr who are apparently contemplating suicide are referred to specialist mental health teams, and how they are kept under review:
Report Sections
Circumstances of the Death
The deceased had a long history of substance misuse. He also had significant history of mental health problems. He had been seen by the psychiatric nurse attached to the Homeless Healthcare Team; His last appointment from the records provided lo the inquest was in July 2017 On 17th October 2017 , Martin was found deceased from the combined toxic effects of prescribed and non-prescribed medication.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.