On the 29th November 2016 I concluded the Inquest into the death of Thomas Josef Green date of birth [st November 994 who died on the ]0t June 2016 at his home address in Denton; Tameside Manchester: [recorded that the deceased had a complex background. He had been assaulted in 2011 and also involved in a road traffic collision. These together with other life events wele felt to have led to a diagnosis of post traumatic stress Jisorder: The medical cause of death was confirmed as la) Asphyxiation secondary to hanging Conclusion Deceased taken his own life CIRCUMSTANCES OF THE DEATH The Inquest into the death of Thomas Green had heard evidence that in August 2011 at the age of 16 he was assaulted. Following this he had difficulties leaving the house and became more isolated. On the first occasion he ventured out he was involved in road traffic collision whereby as & pedestrian he was hit by & motor vehicle which didn't stop, sustaining injuries to his head and The Court heard that following this the deceaseds behaviour and personality totally changed. He was a virtual recluse, over time he became violent towards family members; he became paranoid and had mood swings. In September 2014 he was referred to the Early Intervention Team as he had expressed both suicidal and homicidal thoughts:_ Throughout October 2014 his violent behaviour had legs: escalated towards family members and on the 134 November 2014 he was sectioned under Section 2 Mental Health Act: He remained an inpatient under the care of from the 13.11.14 until the 5.12.14. his admission he was diagnosed with Post traumatic Stress Disorder: Despite his inpatient status he was referred by] on the 20u Novembet 2014 to General Adult Psychiatry due to his "mixed personality disorder with paranoid and antisocial traits. It was unclear what happened with this referral but it was noted, as stated that this referral was made whilst Mr Green was an inpatient. Whilst an inpatient Mr Green was also diagnosed as pineal tumour: On his discharge from hospital Mr Green was placed under the Home treatment team. He remained under the Home Treatment team until 1st April 2015 at which stage he was discharged back to his GP. On his discharge hospital there was no follow-up by Consultant Psychiatrist nor was there any referral for treatment for his diagnosis of Post traumatic stress disorder_ In July 2015 his GP made & referral to Tameside and Glossop Healthy Minds for one to one CBT. He had his first assessment on the 26th October 2015 at which stage he had PHQ 9 score of 25 and a GAD score of 17. Due to difficulties attending and sporadic contact Mr Green was discharged the Service. A further referral was made by his GP in 2016 and the deceased was on waiting list at the time he died. CORONERSCONCERNS The concers noted by the Court the course of the Inquest are as follows: Pennine Care_NHS Trust_Churchgate Surgery_and Tameside and Glossop CCG It was unclear why & referral was made to Adult General Psychiatry whilst Mr Green remained an inpatient there was no evidence that this referral was ever considered or actioned.
2. Hence when Mr Green was discharged from hospital there was no psychiatric follow-up and no treatment plan in place to address the diagnosis of complex PTSD. When & referral was made this was made to Healthy Minds. The Court heard evidence how this was not & case which was suitable for Healthy Minds as it was complex and involved potentially complex PTSD. The Court heard evidence that the referral document completed by the GP was not particularly detailed and therefore the complexity of the case was not apparent and the case was accepted.
5. The Court heard evidence that there is commissioning_gap_for_the_ During having from from May during provision of services for Complex PTSD and complex presentations such as that of Mr Green: 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report; namely by 141fprl2017 [, the coroner; may extend the period: Your response must contain details of action taken or proposed to be taken, out the timetable for action: Otherwise you must explain why no action is proposed. COPIES and PUBLICATION [have sent a copy of my report to the Chief Coroner and t0 the following Interested Persons namely, the family of Thomas Green: [am also under a to send the Chief Coroner a copy of your response: The Chief Coroner may publish either or both in a complete or redacted or summary form; He may send & copy of this report to any person who he believes may find it useful or of interest: You may make representations to me, the coroner; at the time of your response, about the release or the publication of your response by the Chief Coroner. 16.02.2017 Joanne Kearsley Area Coroner Ou1 setting duty

The Inquest into the death of Thomas Green had heard evidence that in August 2011 at the age of 16 he was assaulted. Following this he had difficulties leaving the house and became more isolated. On the first occasion he ventured out he was involved in road traffic collision whereby as & pedestrian he was hit by & motor vehicle which didn't stop, sustaining injuries to his head and The Court heard that following this the deceaseds behaviour and personality totally changed. He was a virtual recluse, over time he became violent towards family members; he became paranoid and had mood swings. In September 2014 he was referred to the Early Intervention Team as he had expressed both suicidal and homicidal thoughts:_ Throughout October 2014 his violent behaviour had legs: escalated towards family members and on the 134 November 2014 he was sectioned under Section 2 Mental Health Act: He remained an inpatient under the care of from the 13.11.14 until the 5.12.14. his admission he was diagnosed with Post traumatic Stress Disorder: Despite his inpatient status he was referred by] on the 20u Novembet 2014 to General Adult Psychiatry due to his "mixed personality disorder with paranoid and antisocial traits. It was unclear what happened with this referral but it was noted, as stated that this referral was made whilst Mr Green was an inpatient. Whilst an inpatient Mr Green was also diagnosed as pineal tumour: On his discharge from hospital Mr Green was placed under the Home treatment team. He remained under the Home Treatment team until 1st April 2015 at which stage he was discharged back to his GP. On his discharge hospital there was no follow-up by Consultant Psychiatrist nor was there any referral for treatment for his diagnosis of Post traumatic stress disorder_ In July 2015 his GP made & referral to Tameside and Glossop Healthy Minds for one to one CBT. He had his first assessment on the 26th October 2015 at which stage he had PHQ 9 score of 25 and a GAD score of 17. Due to difficulties attending and sporadic contact Mr Green was discharged the Service. A further referral was made by his GP in 2016 and the deceased was on waiting list at the time he died.

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action.

Pennine Care_NHS Trust_Churchgate Surgery_and Tameside and Glossop CCG It was unclear why & referral was made to Adult General Psychiatry whilst Mr Green remained an inpatient there was no evidence that this referral was ever considered or actioned.
2. Hence when Mr Green was discharged from hospital there was no psychiatric follow-up and no treatment plan in place to address the diagnosis of complex PTSD. When & referral was made this was made to Healthy Minds. The Court heard evidence how this was not & case which was suitable for Healthy Minds as it was complex and involved potentially complex PTSD. The Court heard evidence that the referral document completed by the GP was not particularly detailed and therefore the complexity of the case was not apparent and the case was accepted.
5. The Court heard evidence that there is commissioning_gap_for_the_ During having from from May during provision of services for Complex PTSD and complex presentations such as that of Mr Green: 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report; namely by 141fprl2017 [, the coroner; may extend the period: Your response must contain details of action taken or proposed to be taken, out the timetable for action: Otherwise you must explain why no action is proposed. COPIES and PUBLICATION [have sent a copy of my report to the Chief Coroner and t0 the following Interested Persons namely, the family of Thomas Green: [am also under a to send the Chief Coroner a copy of your response: The Chief Coroner may publish either or both in a complete or redacted or summary form; He may send & copy of this report to any person who he believes may find it useful or of interest: You may make representations to me, the coroner; at the time of your response, about the release or the publication of your response by the Chief Coroner. 16.02.2017 Joanne Kearsley Area Coroner Ou1 setting duty