UK Inquiry Tracker

Daniel Maher

PFD Report Historic (No Identified Response) Ref: 2017-0124

Date of Report 18 April 2017

Coroner Anna Crawford

Coroner Area Surrey

Response Deadline est. 28 July 2017

Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

No published response · Over 2 years old

Sent To

Response Status

Responses 0 of 2

56-Day Deadline 28 Jul 2017

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

During the course of the inquest the court heard evidence from mental health professionals working on behalf of both West Sussex County Council and SAPB. The court was told that it was not an uncommon occurrence for patients who are detained in Surrey under 8.136 MHA to be taken to Langley Green Hospital in West Sussex for assessment and then, at some thereafter; to be released back into the care of the community health services in Surrey. Given that this is not an uncommon occurrence [ have concerns regarding the sharing of information as between the respective mental health services in West Sussex and Surrey. The court was told that mental health professionals cannot access patient information which is held on the computerised systems of mental health services outside their own county _ As a result; police _ police Act May They being May May point they are dependent on seeking that information directly from their colleagues in other counties, which the court was told was a time consuming process and also impracticable in relation to mental health assessments carried out during anti-social hours. The court was also told that it is common practice, after a mental health assessment has been completed at the s.136 suite at Langley Green Hospital, for a verbal referral to be made by telephone in respect of patients referred to community mental health services outside of the county. The court was told that paperwork, such as the clinical record of the 8.136 assessment; is not routinely shared on the making of such referrals. In fact that the Approved Mental Health Professional employed by West Sussex County Council indicated that she was not allowed to fax such paperwork to other agencies for reasons of data protection: As a result of the above I am concerned that significant information relating to the clinical presentation and risk of vulnerable individuals is not easily accessible by the relevant healthcare professionals, in circumstances in which an individual is assessed at the s.136 suite in West Sussex, and has either previously been under the care of, or is referred back into the care of,mental health services in Surrey. Consideration should be given to whether any can be taken to address the above concerns_

Action Should Be Taken

Report Sections

Investigation and Inquest

The inquest into the death of Mr Maher was opened on the 1 June 2016 and was resumed and concluded on 5*h April 2017 . The cause of death was: 1a - Hanging The inquest concluded with a conclusion of Suicide:

Circumstances of the Death

On 26th 2016 Mr Maher was found hanging at his home address The emergency services were called but efforts to resuscitate him were unsuccessful and he was pronounced deceased at the scene: On 23rd 2016 Mr Maher' s partner had found him with a knife at their home address. He was upset and asked his partner to help him to kill Surrey May ' May'

himself, As a result she took him to A&Eat East Surrey Hospital, Whilst they were waiting to be seen Mr Maher left the hospital and, following - search, was found in a nearby field having cut his wrists_ He told the officer who attended that he had tried to kill himself but that the attempt had not worked He was detained by the police pursuant to 8.136 Mental Health 1983 (MHA) and initially taken back to East Surrey Hospital where his wounds were sutured and dressed. He was then taken to the s.136 suite at Langley Green Hospital in West Sussex which; the court was told, is the closest 8.136 suite to East Surrey Hospital, In the early hours of the morning on 24u 2016 Mr Maher underwent an MHA assessment; which was conducted by an Approved Mental Health Professional employed by West Sussex County Council and two 12 MHA approved doctors. jointly assessed Mr Maher a8 suitable for release and referred him into the care of the Home Treatment Team (HTT) in his home county of Surrey, which falls under the auspices of Surrey and Borders Partnership (SABP) On 24th 2016 Mr Maher was seen by a Registered Mental Health Nurse with the HTT and on 25 2016 he was seen by a psychiatrist with the HTT, and he remained under their care at the time of his death:

Copies Sent To

Ihave sent a cOpY of this report to the following: being key history, steps 1, 2, 3_ 4