On 07/12/2016 I commenced an investigation into the death of Lee Joseph HASTINGS SWAIN, Aged 28. The investigation concluded at the end of the inquest on 16/06/2017.

The medical cause of death was: Ia Hanging

The conclusion of the inquest was:

Lee Joseph Hastings Swain took his own life whilst the balance of his mind was disturbed. Lee Joseph Hastings-Swain was a 28 year old gentleman who suffered from Schizoaffective disorder and had been diagnosed with psychosis approximately 10-12 years ago for which he was prescribed Olanzapine and had received depot injections over the years. Lee was under Sefton mental health team (Mersey Care NHS Trust Foundation) and more recently Wirral Mental Health Team (Cheshire and Wirral Partnership NHS Trust). On 30 November 2016 Lee was found deceased hanging from the bannister at his home using a bed sheet. On the bed Lee had left an undated handwritten note suggestive of the fact he was suffering from severe emotional difficulties. Toxicology analysis showed nothing of significance which caused or contributed to Lee’s death. It is unclear as to what Lee’s intentions were when carrying out the act of self-harm but it is clear that he was suffering from mental health related symptoms and so his mind was disturbed. Lee had been under the care of Mersey Care NHS foundation since July 2005. During the years Lee’s engagement was sporadic and he was placed on a Care Programme Approach(CPA), however subsequently he was taken off the programme on the basis of other clinical regular appointments. In March 2016 Lee moved to Wirral and Mersey Care discharged Lee from their services and referred him to Cheshire Wirral Partnership (CWP) via the General Practitioner (GP). In May 2016 The Wirral GP referred Lee to the CWP who failed to make contact with Lee and an assessment never took place. Within the Mental Health Services, the following failures occurred in the care and treatment of Lee: Mersey Care inappropriately removed him from the CPA when he clearly needed the continuity and engagement; Lee’s care was not co-ordinated across services. Referrals through the GP were made rather than a transfer from service to service. If Lee had remained under the CPA the transfer would have been more effective – service to service; Despite Knowing that Lee was moving to the Wirral in March 2016 a referral letter with the clinical history was not sent until June 2016 which was an unacceptable delay; Cheshire Wirral Partnership Mental Health Services’ Staff failed to adhere to Operational procedures in that the clinical notes were poor and inadequate. The notes were brief and did not fully detail decisions made or rationale for those decisions; CWP engagement with Lee fell short of expected standards, essentially comprising of appointment letters to his home address. The pattern of non-attendance should have triggered a more pro-active response to engage Lee with the service. There were a number of failures by the mental health services. It is unclear as to whether a more effective transfer from one service to another and thus earlier and more pro-active intervention would have changed the outcome for Lee, however, there were clear missed opportunities for further intervention to help and support Lee. A more co-ordinated approach from the mental health services may have given better opportunities to engage Lee so that he could have received the support and treatment he so desperately needed.