On the 5th January 2019, evidence was heard touching the death of Peter George Garvin. Mr Garvin, had entered the Regent's Canal in Westminster on 31st January 2018, with the intention of taking his own life. He was 86 years old at the time of his death: The findings of the court were as follows: Medical Cause of Death Drowning How; when and where the deceased came by her death: Mr Garvin was suffering with a second episode of treatment resistant depression. He had previously attempted to take his own life in October 2017. At or around 10.35 on 31st January 2018 he entered the Regent's Canal in Westminster with the intention of taking his own life. There was no third party involvement He was recovered and recognised as life extinct at 12.27 . Conclusion of the Coroner as to the death: Mr Garvin took his own life whilst suffering with depressive illness. (a)

Circumstances of the death: At the time of his death Mr Garvin was under the care of the Community Mental Health Team, however his medication was prescribed by his GP There were intermittent communication problems between the CMHT and the GP re his prescribing: In October 2017 he had required admission but due the lack of local beds he had been hospitalised in Milton Keynes. Mr Garvin's illness placed a lot of strain on his elderly wife, but she was not offered a carer's assessment prior to his death: His illness was treatment resistant; and he asked for private psychiatric assessment in a search of a cure. He saw a private psychiatrist on 19th January 2018. When the CMHT became aware that he had sought private treatment he was informed that he would be discharged from the CMHT He was informed of this by his CPN at a home visit of 29h January 2018. This had a significant adverse effect on his mood. Just two days later; he took his own life. It is the policy of Mr Garvin's consultant to discharge patients from NHS care if they are taken for private treatment; apparently due to concern over potential communication difficulties_ The private psychiatrist stated in evidence that she could only have seen Mr Garvin intermittently in out patients which in her view he was too ill or admit him to hospital. This would have deprived Mr Garvin of the option of being cared for at home in the community_ Concerns of the Coroner: That there should be a system of doctor to doctor communication to facilitate prescribing, for example through direct email contact: That there should be sufficient local beds so that such a vulnerable person should not have to be hospitalised so very far from home: That if patients seek private psychiatric care should not be discharged by the NHS. Instead a memorandum of understanding should be agreed between the NHS and Private psychiatric consultants to allow joint working and facilitate patient care. This should surely be possible along the lines of such agreements with GPs_ That carer's assessment should be undertaken early in the patient treatment pathway: