Edward Lundy
PFD Report
Historic (No Identified Response)
Ref: 2018-0087
Coroner's Concerns (AI summary)
Poor continuity of care, inadequate family consultation on discharge risks, and lack of evidence for implementing recommended improvements in mental health risk management for GP trainees were identified.
View full coroner's concerns
_ _ The South London and Maundsley NHS Foundation Trust The Trust') completed it's own Mental Health Investigation Report under the NHS England Serious Incident Framework: The investigation was conducted by Consultant Liaison Psychiatrist; St Thomas' Hospital and Team Leader of Lewisham PMIC Treatment Service. The Report acknowedges that Edward Lundy was known to the Trust since 15th July 2016 being reported initially to Lambeth Assessment and Liaison Team and then to the Lambeth Living Well Network Hub where Edward was seen twice on 10th and 18th August 2016. Lambeth Hub contacted Wandsworth IAPT with a view to requesting that psychological therapy be re-started and an appointment was made for August 2016 The Trusts own findings identified a number of issues and a number f proposed actions. Edward Lundy had contact with many professionals in a short period of time and that affected the continuity of his care. Proposed action to set up joint services review with Old Municipal Buildings; Corporation Street; Taunton; Somerset; TAI 4AQ Tel 01823 359271 Fax 01823 355060 for Tony The 24th _
provider organisations involved with an oversight report to be produced. That upon Edward Lundy's discharge into the care of his family, there should have been independent consultation with the family and this should have been documented with the risks being explicitly discussed. Proposed action to ensure that the Psychiatric Liaisons Operational Policy stated as such and to disseminate to all Iiaison teams via pathway meetings and local business meetings. That the doctor referring Edward to the Lambeth Assessment and Liaison Team should have made it clear that he believed Edward should be seen by a psychiatrist: Proposed action that the Training Lead in the Trust be informed that GP trainees should receive risk management training, focussing on crisis intervention services e.g: when to consider CMHTIHome Treatment Team/lnpatient Admission_ There has been no evidence produced as to compliance with the recommended actions_ There has been no evidence produced as to the findings of the report and its proposed actions being started nationally so as to inform other Mental Health Trusts_ That the family received no information as to the proposed actions having been followed through and any resultant changes in procedure_ Old Municipal Buildings, Corporation Street; Taunton; Somerset; TAI 4AQ Tel 01823 359271 01823 355060 Fax
provider organisations involved with an oversight report to be produced. That upon Edward Lundy's discharge into the care of his family, there should have been independent consultation with the family and this should have been documented with the risks being explicitly discussed. Proposed action to ensure that the Psychiatric Liaisons Operational Policy stated as such and to disseminate to all Iiaison teams via pathway meetings and local business meetings. That the doctor referring Edward to the Lambeth Assessment and Liaison Team should have made it clear that he believed Edward should be seen by a psychiatrist: Proposed action that the Training Lead in the Trust be informed that GP trainees should receive risk management training, focussing on crisis intervention services e.g: when to consider CMHTIHome Treatment Team/lnpatient Admission_ There has been no evidence produced as to compliance with the recommended actions_ There has been no evidence produced as to the findings of the report and its proposed actions being started nationally so as to inform other Mental Health Trusts_ That the family received no information as to the proposed actions having been followed through and any resultant changes in procedure_ Old Municipal Buildings, Corporation Street; Taunton; Somerset; TAI 4AQ Tel 01823 359271 01823 355060 Fax
Sent To
- South London and Maudsley NHS Trust
Response Status
Linked responses
0 of 1
56-Day Deadline
11 Aug 2018
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 24/08/2016 | commenced an investigation into the death of Edward Arthur Lundy, 23 The investigation concluded at the end of the inquest on 05/12/2017. The conclusion of the inquest was "Suicide. During the course of diagnosis and treatment Edward Lundy was not seen by a psychiatrist; care options were not documented and discussed with family members and he was seen by numerous different health care professionals" recorded that on 23rd August 2017 at West Combe Farm, Huish Champflower Edward Lundy deliberately suspended himself by the neck with the intention of ending his life.
Circumstances of the Death
Edward had a history of depression_ He had been staying with a friend's family and was last seen alive when he went for a walk at about 10.00 hours on 23.08.16. friend's mother went looking for him and found him hanging by the neck from a rope secured to a beam in a barn in a field on the family farm. He had secured wrists together in front of him with a cable tie_ A note was also discovered at scene with his rucksack and a sports bottle containing alcohol. He was cut down and given CPR whilst ambulance was called but could not be revived.
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.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.