On 20 September 2020 I commenced an investigation into the death of Robert Arthur Brown, 68. The investigation concluded at the end of the inquest on 30 November 2021. The conclusion of the inquest was that Mr Brown died from 1(a) Severe Head Injury (b) Fall 2. Self-harm. The conclusion of the inquest was Suicide.

Robert Arthur Brown had a history attempts to take his own life and of suicidal ideation. He was under the treatment of mental health trust during 2020. Mr Brown was assessed as being a high risk of suicide on 3 September 2020. He reluctantly agreed to an admission as a voluntary patient to hospital. At this time, the family and Crisis Team could not keep Mr Brown safe in the community. His wife was known to be his carer and had taken responsibility for Mr Brown’s medication. Mr Brown remained in hospital for four days. On the 4th day he indicated he wished to be discharged. He indicated that he no longer had suicidal thoughts and appeared to have made plans as to the changes that he was going to make which differed from those previously. He was assessed by the clinicians for discharge, and this was agreed. Mr Brown’s wife was not contacted and advised that he would be discharged. Mrs Brown only became aware of this when Mr Brown was in transit back to his home address. The evidence from the clinicians was that Mr. Brown had capacity and did not want them to contact Mrs. Brown and that he would make her aware of his discharge. The instruction by Mr Brown not to inform Mrs Brown was not documented and the oral evidence from KMPT witnesses was that they could not inform Mrs Brown as this would be contrary to Mr Brown’s wishes. On 9 September 2020, Mr Brown was found fatally injured at the cliffs close to his home address. A Root Cause Analysis Report (‘the Report’) prepared by KMPT and evidence was heard at inquest as to the findings. The Report included a finding that the ward should have contacted Mrs Brown to contribute to the discharge planning but did not do so. The Report recommended that where there had been carer breakdown then there should be discussion with that carer on admission and discharge. At inquest a witness was called to advise on the implementation of the Improvement Plan but was unable to explain to the Court the meaning of “carer breakdown” and when the actions would therefore be engaged. Subsequent documentation from KMPT provided evidence of the liaison with carers but did not address the identification of “carer breakdown” and how this would be addressed on a discharge where there was no CPA in place.